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Module 7 > UNIT 2: CARE OF THE RESP. PT 2 > Flashcards

UNIT 2: CARE OF THE RESP. PT 2 Flashcards

1
Q

What are the indications for mechanical ventilation?

A
  1. Apnea, Airway protection
  2. Acute Respiratory failure
  3. Severe Hypoxia
  4. Resp. Muscle Fatigue
  5. Upper airway obstruction
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2
Q

What are the types of artifical airways?

A
  1. Endotracheal (ETT)
    • Emergent or planned
    • Short duration (10-14 days)
  2. Tracheostomy (trach)
    • Usually planned
    • Surgical Procedure
    • At bedside or in operating room
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3
Q

What are commonalities of both an endotracheal and tracheostomy airway?

A
  1. Emergent or planned
  2. A way to assist with ventilation
  3. Both can be connected to bag-valve-mask (BVM) to assist with breaths
  4. Ventilatior
  5. Oxygen by trach collar (trach) or t peice (ETT)
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4
Q

What are some examples of non-invasive ventilation systems?

A
  1. High-flow nasal cannula
  2. BIPAP
  3. CPSP
  4. AVAPS

Noninvasive ventilation is often tried for patients who may need assistance ventilating for a short time before weaning or discontinuing. If unsuccesful due to lack of toleration, ineffectiveness or if patient is expected to need more support, they may be intubated

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5
Q

What are invansive ventilation systems?

A
  1. endotracheal tube
  2. Tracheostomy
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6
Q

What do we need to know about the endotracheal cuff?

A
  1. The cuff is located at the distal end of the tube, when inflated produces a seal between the trachea and the cuff to prevent aspiration and ensure delivery of a set tidal volume when mechanical ventilation is used. An inflated cuff also prevents air for passing to the vocal cords, nose, an mouth.
  2. Too much air can cause tracheal erosion
  3. Too little air in the cuff can cause accidental excubation.
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7
Q

What is the expected outcome/goals of care for a ventilated patient

A
  1. Support patient until underlying condition is corrected
  2. Maintain or correct hypoxia/ventilation
  3. Provide supplemental oxygen
  4. Prevent complicaiton and maintain patient safety
  5. Provide EBP, holist family centered care and integrate human caring
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8
Q

What should we do prior to ETT intubation procedure?

A
  1. Obtain permit if not emergent procedure
  2. Obtain supples and assist provider
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9
Q

After ETT insertaion what do we need to do?

A
  1. Confirm placement of ET tube
    • pt still being manually ventilated using the BVM with 100% o2
  2. Assess end-tidal Co2 detector
    • Place the detector between the BVM and ET tube and either look for color change or number. If no co2 is detected, the tube is in the esophagus and needs to be reinserted.
    • Yellow yes, Purple we have a problem.
  3. Auscultate lungs bilaterally
    • looking for absent air sounds (not what we want)
  4. Ausculate epigastrium
    • Looking for absent air sounds(if we here air we are in the incorrect tube)
  5. Observe chest wall movement
    • Equal and bilateral.
  6. Monitor spO2’
    • should be stable or improved
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10
Q

ETT intubation and patient safety… What should we know…

Must know ETT cuff pressure.

A
  1. Inital assessment of ETT placement
    • Capnometer to check ETT placement in trachea
    • “yellow says yes”, change from purple to yellow indicates presence of Co2
  2. Chest x-Ray
    • End of ETT should be 3 to 4cm above carina
  3. ETT cut pressure should be **<25 cm **H20 or minimal leak technique
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11
Q

What should we keep in mind about accidental dislodgment of the trach?

A

Obturator at bedside Always! Place obtrurator call MD. Provide oxgen support as needed.

  1. Tube cannot be replaced because if tract immaturity (less than 1 week old) or other circumstances,
  2. Immediately place the patient in semi-fowlers position to decrease dyspnea.
  3. Cover the stoma with a sterile dressing and provide ventilation with the BVM over the nose and mouth.
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12
Q

How do we know if the patient is tolerating our trach care?

A

Assess for patient. Looking for dsats, increased rr.

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13
Q

Tracheostomy Care includes?

A
  1. Ensure obturator is at the bedside for emergencies
  2. Clean face plate or flange
  3. Clean the stoma qshift & PRN
    • Clean with sterile saline & dry
    • Change the dressing
    • Change securement ties if soiled (unless trach is new, then check orders)
  4. Change inner cannula qshit & PRN
  5. Reassess patient after procedure.
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14
Q

What is our nursing care for artifical airways?

A
  1. Oral care q4 hours
  2. In-line suctioning qshift and PRN
    • Must have indications of needing suctioned like o2 sat is down, rr up, tachycardic, restlessness, coughing
  3. Reposition & provide passive ROM
  4. Change pulse oximeter and ECG patches q24 hours
  5. Patient/family teaching as needed
    • Families are not always educated well on vents
  6. Talk to the patient
    • Always assume that they can hear.
  7. Restraints for safety; restraint releasse q2 hours & skin assessment
    • ROM, Turning is important
  8. Provide time for sleep and rest
  9. Limit suction to no more than 10 seconds.
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15
Q

What medications can be usedd for mechanical ventilation?

A
  1. Paralytics- Never give a paralytic without a sedatives
  2. Sedatives
    • Propafol, versed, medazolam
    • can cause pressures to decrease which may be a reason they give vassopressors
  3. Opioids
    • Fentanyl- given with intubation and then as a drop to help relax.
  4. Vassopressors/fluids/volume expanders
    -R/t the pressure within the lungs.. decrease cardiac output and volume isnt able to get where it needs to go
  5. Bronchodilators
    • Airway might be clamped down so this will help relax
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16
Q

What are our LEAN drugs?

A

1.Lidocaine
2.Epi
3.Atroprine
4.Narcan

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17
Q

What is our patient safety for ETT and traches?

A
  1. ensure tube is secured
    • PRIORITY- make sure to confirm placement by the marking measurement, ausculate, chest xray and cuff pressure @ 25
  2. Keep tube patent
    • Listen, suction, alarms customized to patient.
  3. Verify/maintain placement
  4. Monitor resp. status
  5. Bag valve mask (BVM) in room
  6. Keep scissors airway from external balloon
  7. Room set up
    • know what you need at beside
  8. Restraint use
    • know when they should be used… add after lecture
  9. HOB at or above 30 degrees if not contraindicated
  10. Validate suction setup and know how to use

Look at how the patient is tolerating the ETT/Trach- are they usuing accessory muscles, retratctions present, hows the cardiac monitor (PVC PAC), color, rr o2 sats normal?, what is the enviroment in the room like.

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18
Q

How does in line suctioning work?
REDO- listen to lecture need to know perfect steps.

A
  1. Gently insert catheter until resistence met.
    Apply suction while withdrawing catheter. Suction max 10 seconds
  2. Validate catheter is completely out of ETT or trach tube by visualizing location of black mark on tip of in-line catheter
  3. Monitor ECG and SpO2 before, during and after suctioning.
  4. ONLY apply suctioning when withdrawing catheter
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19
Q

Why is inline suctioning perferred?

A

Helps prevent infection of the patient because it is a closed system and it protects you as well. It also helps prevent loss of PEEP and o2 that occurs when the ETT or trach is disconnected from the ventilator and suctioning.

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20
Q

What are potential complicaitons of suctioning?

A
  1. Hypoexemia
  2. Bronchospasm
  3. Increased ICP (may require breaks during suctioning)
  4. Dysrhythimas (PVC, PAC)
  5. increased or decreased bp
  6. Mucosal damage (hitting the corinna)
  7. Pulmonary bleeding, pain or infeciton
  8. They may vagal down so decreased HR
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21
Q

What is f/RR

A
  1. Frequency/respiratory rate (12-20 bpm)
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22
Q

What is I:E Ratio?

A

Inspiratory time compared to expiratory time (1:2)

Basically your exhale is longer than your inahle

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23
Q

What is PEEP?

A

Peek Inspiratory pressure (15-20cmH2O)

Constant pressure that is applied throughout experation. High level is 15. The purpose of PEEP is to keep alvioli open and prevent collapsing of aveoli.

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24
Q

What is PIP?

A

Peak inspiratory pressure (15-20cmH2o)

Max pressure during inspiration. Represents the resisteance to airflow that affects pressure during inhalation.

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25
Q

What is Ve?

NOT as important to know.

A

Minute ventilation/volume (VT xRR) 6-8L/Mins)

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26
Q

What is Vt

MUST KNOW.

A

Tidal volume (6-8ml/kg-ideal body weight) (very sick lungs- 4 to 6 ml/kg)

How big of a breath your taking

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27
Q

What do we need to know about non-invasive: high flow nasal cannula?

A

HFNC:
1. Delievers o2 from 21% up to 100%
2. Delivers the o2 at flow rates up to 60L/min
3. Provides humidication

Function:
1. Clears physiological dead space of expired air
2. Keeps alveoli open at end of expiration

Disadvantages:
1. Limits patient mobility
2. Requires good fit
3. Requires adequate spontaneous RR

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28
Q

What do we need know about non-invasive contionus postive airway pressure (CPAP)

A
  1. A present pressure is provided throughout both the inspiratory and expiratorty phases of the breath
    **2. GOAL- keeps alvoli from collapsing. Resulting in better oxygenation and less work of breathing.
    **3. Only provide airway pressure
  2. Patient must be able to breath spontanously
  3. Patient does ALL of the work.
  4. CPAP can be used in non intubated patient using a face mask or a intubated patient (must be spontaneous breathing if on vent)
  5. CPAP mode may be used to evaluate the patietns readiness for extubation on a ventilatior
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29
Q

Non-invasive: Bi-level postive airway pressure (BIPAP) what should we know?

Dont worry to much about this

A
  1. Used to ventilate non-intubated patients to help prevent intubation. Patient must be able to spontaneously breathe and cooperate with treatment
  2. Settings incude fi02 and 2 pressure settings
    • Insiratory pressure (IPAP) assist ventilation
    • Expiratory pressure (EPAP): assist oxygenation
  3. Must be able to spontaneously breathe and cooperate with this treatment
  4. CPAP and BIPAP both have expiratory pressures.

Especially useful for patientw ith chornic obstructive pulmonary disease (COPD) unable to exhale against higher airway pressure to help resolve Co2 problems

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30
Q

Bi-PAP is used for what patients?

try and knwo this one

A
  1. COPD
  2. hear failure
  3. acute resp. failure
  4. sleep apnea
  5. use after extubation can help prevent reintubation
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31
Q

What patients cannot use BiPAP

A
  1. Shock
  2. Altered mental status
  3. Increased airway secreations

Because of the risk for aspiration and inability to remove the mask

32
Q

What are the expected out comes for non-invasive ventilation?

A
  1. Treatment toleration while trying to get them through there illness
  2. Prevent intubation
33
Q

Freebie card

A
34
Q

How does your body increase Pao2 or how can we assist this clinically?

A

Can increase PIP or can increase Fi02

35
Q

What are we assessing on our patient with a noninvasive ventilation to know if we are getting our expected outcome?

A
  1. ABGs
  2. Chest xray
  3. Perfusion
  4. Color Changes
  5. LOC changes
  6. Alertness
  7. Symetrical breathing
  8. RR
  9. O2 sats
36
Q

What two types of modes are there on a vent?

A

Volume/Pressure modes

37
Q

What are different volume settings on a vent?

MUST KNOW 1

A
  1. Assist control (AC)
  2. Synchonized intermittent mandatory ventilation.
38
Q

What are the different pressure settings on a vent?

Must know 2

A
  1. Pressure support ventilation (PSV)
  2. Postive end expiratory pressure (PEEP)
39
Q

Key settings for why ventilation settings are chosen?

REVIEW only

A
  1. To blow off co2- increase RR and/or VT
  2. To increase Pa02- Increase Fi02 and/or PEEP
40
Q

What do we need to know about Postive Pressure Ventilation?

A
  1. Inflates the lungs by introducing postive pressure and/or volume
  2. Different modes avail on the machine
  3. Used short term or long term
41
Q

Whats important for the nurses to know about positive pressure ventilation?

A
  1. Verify settings/order
  2. Assess patient
  3. Ensure pt safety
  4. Troubleshoot as needed
  5. Monitor ABGs.
42
Q

What do we need to know about Mode Volume: Assist control (AC/ACV)?

A
  1. Full support mode: Controls the work of breathing
  2. AC provides a fixed tidal volume (Vt) that the ventilator will deliver at set intervals of time or when the patient initates a breath.
  3. Vt (tidal volume) will remain the same for patient-initiated breath or ventilator breath
  4. Requires the least amount of patient effor; choice for the very sick patient
43
Q

What do we need to know about modes pressure: Pressure support (PS/PSV)

A
  1. A set airway pressure to assist the patient with spontanous breaths
  2. Usually set at 5-15cmh2o
  3. Decreases work of breathing by giving the patinet a little boost on the breaths they initate on their own
  4. Pressure support is decreassed as the patient improves.
44
Q

What do we need to know about Modes Pressure: Postive End-Expiratory pressure (PEEP)

A
  1. Expiratory pressure setting to apply positive pressure durin gexhalation
  2. 3-20 cm H2O
  3. Improves ocygenation by restoring lung volume
  4. Fi02 can be reduced when Peep is used
  5. Used cautiously in patients with increased ICP, Low CO and hypovolemia…

Can cause pnumothorax

45
Q

What are potiental complications in ventilated patients?

A
  1. Aspiration or abdominal distention, ileus
    • Insert NG/OG to decompress the stomach
  2. Oxygen toxicity
    • Fio2 greater than 50% for more than 24-48 hours
    • S/S: restlessness, dyspnea, chest discomfort, fatigue, atelectasis
  3. Barotrauma
    • Distention of lungs from where the alveolar rupture d/t the pressures in the lungs.
    • Non complient patients, COPD patients, are at an increased risk.
    • Supq emphasema, pneumothorax, pulmonary emphazemia are complictions.
  4. PEEP related issues- hypotension, H2O retention.
  5. Anxiety
  6. Stress ulcers
  7. Infections
    • r/t foriegn lines and machines in body
  8. Muscular decondition
    • ROM is important the longer they lay the worse they get
  9. Malnutrition if nutrition is not maintained
  10. Ventilator dependence or inability to wean
  11. VAP
46
Q

What should we know about VAP in ventilated patients

A

Ventilator-associated pneumonia (VAP)
Occurs 48 hours or more after intubation

47
Q

What are risk factors of VAP?

A
  1. Contaminated respriatory equipment
  2. Inadequate handwashing
  3. Environmental factors
  4. Impaired cough
  5. Colonization of oropharynx
48
Q

What are the guidelines of preventing VAP

A
  1. Minimize dedation and sedation vacations
  2. Provide early exercise and mobilization
  3. Conduct subglottic secreation removal
  4. Elevate HOB 30-45 degrees unless contraindicated
  5. Routine oral care with chlorohexidine
  6. Strict handwashing, wear gloves
49
Q

What our patinets psychosocial nees when on a vent

A

Patient needs to
1. Feel safe
2. know information
3. regain control
4. hope
5. trust
6. involve the patient in decsiion making

50
Q

What is our nursing managment for ventilated patients?

A
  1. assess repiratory status & vital signs q 1-2 horus
  2. Monitor labs
  3. Review chest xray/results
  4. Turn as tolerated/assess skin for breakdown
  5. Prevent ventilator acquired pneumonia
  6. DVT prophylaxis
  7. Provide adequate nutriton (NGT, OGT, PEG)
51
Q

What safety supplies should we assess our patients room for when on a vent?

A
  1. BVM
  2. Suction set up and ready
  3. Are the alarms pulled in and functioning properly, set within parameters
  4. Are restraints secrured properly
  5. Are lines and tubes secured
  6. Can the caregiver adequately monitor the patient and monitor
52
Q

What caregiver safety should we consider when caring for a vent pt

A
  1. Wash hand and don appropriate PPE for untiversal percautions
  2. maintain closed circut of the vent
  3. Be mindful of stance and actions with suctioning w/trach
  4. perform pt positioning (prone or supine) with proper ergnomics and pt equipment
  5. have adequate staff to reposition patient/airway
  6. Monitor restraint use as needed/ordered
  7. Have a plan for agitation restlessness
    • Have a plan in mind… do we need to advocate for different sedation…
  8. Foster comfort and communication.
53
Q

What should know about prone positioning?

A
  1. Used in patients having severe oxygenation issues
  2. Goal- Improve oxygenation by decreasing the pressure on the lungs from the abdominal contents, heart and supporting structures, and added weight of the lungs
  3. Must have doctor order
54
Q

What are contraindications for prone positioning?

A
  1. Shock
  2. Multiple fractures or trauma
  3. Pregnancy
  4. Raised ICP
  5. Tracheal surgery or sternotomy within two weeks
55
Q

What questions should we ask ourselves when trying to determine if a patient is ready to be weaned off the vent?

A

Is the patient
1. Breathing spontanously
2. Supporting adeqate oxygenaiton
3. Maintaining normal hemodynamics
4. Has the original reason for intubation resolved?

56
Q

What are signs of intolerance to weaning the patient from the vent?

A
  1. Increase or decrease RR
  2. Increase HR
  3. Decrease SaO2 sustained below 90%,
  4. Respiratory distress
  5. LOC change
  6. Arrhythmias
  7. Agitation or anxiety
  8. Low tidal volumes
57
Q

What should we know about the extubation process?

A
  1. Hyperoxygenate and suction the ETT and oral cavity
  2. Semi-fowlers position
  3. deflate cuff, have patient inhale and at peak inspiration remove tube while pulling it out
  4. After removal instruct to cough and deep breath
  5. Apply oxygen as ordered
58
Q

What is the role of the nurse in an event that there is accidental extubation?

A
  1. Assess patient quickly. How is patients respiratory effort and o2 sat
  2. Call for help
  3. If patient needs ventilation assistance ensure the bag valve mask is attached to the o2 flowmeter and o2 is on
  4. Attach the face mask to the bvm and ensure a good seal on the patients face, supply the patient with ventilation.

Assist control setting patients we are more worried

59
Q

What type of alarm would we get for a cuff leak? and what would be our intervention?

A

Low pressure- assess for cuff leak, check cuff pressure, call RT and phsycian

60
Q

What alarm would sound for a leak in the ventilator circut and what would our intervention be

A

Low-pressure: assess all connections and tubing; call RT and physcian, a new vent may be needed

61
Q

What alarm would go off if you have a patient that stops breathing in the pressure support modes of SIMV and what are our interventions?

A
  1. Assess the pt; notify rt and md; may need to provide manual breaths via BVM
62
Q

What alarm would sound with an unintentional extubation and what are our interventiosn?

A
  1. Assess patient for need to be reintubated; apply oxygen; may need to give manual breaths via BVM
63
Q

What alarm would sound with a tube disconnected from circut and what would be our intervention?

A

Low pressure alarm: Reconnect tubing to circut, assess patient

64
Q

What is alarm would go off with a patient with barotruma and what would be our interventions?

A

Low pressure alarm
Assess subcutaneous emphysema- notify RT and md if present

65
Q

What alarm would sound if you have a pt with mucous plug or increased secreations on a vent and what are our interventiosn

A

High pressure
suction as needed

66
Q

What alarm would sound if a patient bites ETT and what would be our intervention?

A

High pressure
insert an oral airway to prevent biting (bite block)

67
Q

What alarm would sound for a pt with a pneumothorax on a vent and what would be our intervention?

A

High pressure
Assess asymmetrical chest rise, decreased breath sounds of pneumothorax site;; notify MD

68
Q

What alarm would sound for a patient that is anxious and fighting the vent and what would be our intervention?

A

High pressure
Assess the patient, provide emoitonal support, re-evaluate sedation/analgesic need

69
Q

What alaram would sound if there was kink in the vent tubing and what would be our intervention?

A

High pressure
Assess the tubing from vent to pt to ensure no kinking of tube is present

70
Q

What alarm would sound in water was collecting in the vent tubing and what would be our intervention?

A

High pressure
Empty water from the tubing

71
Q

What alarm would sound if the pt is coughing and what intervention would we do?

A

High pressure
Continue to monitor

72
Q

What alarm would sound if a pt on a vent was experiencing bronchospasm and what would be our intervention

A

High pressure
Assess for non-productive consistent coughing, give a breathing treatmetn

73
Q

What alarm will sound when a patient has pulmonary edema on a vent and what are our interventions?

A

High pressure- Assess lung sounds and ETT for fluid; suction needed, may need to be placed prone and fiven diuretics

74
Q

What alarm will sound when we have a pt with decreased lung complience on a vent and what would be our intervention?

A

High pressure
Assess lung sounds, rr, bp, saO2, notify RT, md, ventilator mode may need to be changed

75
Q

What do we need to know about arterial line and monitoring?

A
  1. Placed for contionous vital sign monitoring and frequent blood draws esp. ABGs
  2. Usual location- radial or femocral artery
76
Q

What safety info should we know about arterial line and monitoring?

A
  1. 0.9% NS used as fluid for pressurized system
  2. NO meds given per aterial line
  3. Monitor extremity ciruclation
  4. Pressure system 300 mmhg
  5. Tranducer level at phlebostic axis
  6. no circumferntial dressing/tape

Module 7 (22 decks)

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