Week 9: Mechanical Ventilation - Start of Exam 3 Flashcards

1
Q

Oxygen

A

A medication that needs an order to survive

Can have standing orders though or use in emergent situations

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2
Q

At what concentrations is O2 administered

A

ones higher than RA so greater than 21%

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3
Q

Goals of O2 Therapy

A

Decrease Workload of heart and lungs

Increase tissue perfusion

Adequate transport of O2

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4
Q

Nasal Cannula

A

low flow (1-5 L at 24-40%/ 6L at 44%) or high flow (10-15 L at 65-90%) device where nares need to be in the nose to work

Can be an issue with mouth breathers

air can be humidified or non-humidified

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5
Q

What is are important nursing interventions for nasal cannula?

A

Watching for COPD patients as their O2 goal is 88-92 %

Knowing that high flow nasal cannula are often better tolerated by children

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6
Q

Simple Mask

A

Has tubing like the nasal cannula but has vents that allow the exhaled CO2 to escape

A low flow device at 5-8 L/min at 40-60%

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7
Q

Nursing intervention/consideration for a simple mask

A

May need nasal cannula at meals

Those with calustrophobia hate the feeling

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8
Q

Partial Rebreather Mask

A

Has a reservoir bag for part of the patients exhaled air while also having vents like the simple mask allowing remained exhaled air to escape

Exhaled air trapped in bag mixes wiht 100% O2 for next inhalation so you rebreathe 1/3 of expired air allowing for O2 conservation

Also, the vents allow breathing in room air too if somehow O2 from the flowmeter is interrupted

BREATHING OUT SOME AIR BUT A MIX OF RA AND O2 COMES BACK

Does low flow 8-11 L at 50-75%

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9
Q

Nursing intervention for a partial rebreather mask

A

watching for kinks in bags and tubing

skin checks

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10
Q

Nonrebreather Mask

A

similar to partial rebreather but it has 2 one way valves not allowing any exhaled air rebreathing - only supplied O2 gets into the bag

need to plug the vent so bag fills with O2 and they do not suffocate

does Low flow 10-15 L at 80-95%

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11
Q

Which oxygen delivery system delivers the highest O2 concentration

A

Nonrebreather at 80-95% as no rebreathing of exhaled air occurs

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12
Q

Venturi Mask

A

Has a large tube with an O2 inline allowing pressure to drop and air to build up in side ports

Ports can be adjusted for very precise O2 concentration but need to be open (the liters and % on each venturi mask part)

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13
Q

What is the exception for COPD patients for O2 delivery systems

A

Venturi Mask

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14
Q

The most precise O2 delivery comes from what device

A

Venturi Mask

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15
Q

What are some other methods of O2 Therapy (beside delivery devices)

A

Nebulizer

IPPB

CPAP

Bi PAP

Ventilator

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16
Q

Nebulizer

A

Used to ain in bronchial hygiene by hydrating dried secretions, promoting expectoration of secretions, humidifying inspired O2 and delivering medication deep into lung fields

Can be with or without medication delivery

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17
Q

IPPB - Intermittent Positive Pressure Breathing

A

A machine that administers either RA or O2 at a pressure higher than atmospheric pressure

It also aids in delivery of inhaled medication like a nebulizer does

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18
Q

How does the Nebulizer and IPPB compare

A

Neither is better than the other, but IPPD can be used to treat atelectasis and promote airway clearance, especially in those not doing well with IS or chest physiotherapy

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19
Q

PAP - Positive Airway Pressure

A

a method of O2 therapy used to keep airways open by use of mild air pressure

can be used for sleep apnea including OSA, heart failure, and obesity hypoventilation syndrome

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20
Q

NIPPV

A

noninvasive positive pressure ventilation

includes PAP

2 types: BiPAP and CPAP

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21
Q

What patients is NIPPV good for

A

those who cannot undergo intubation or invasive ventilation with the goals of decreasing the work of the respiratory muscles and relieve dyspnea

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22
Q

CPAP - Continuous positive airway pressure

A

method to keep airways open by providing constant mild air pressure

it helps hold the airway open, mobilize secretions, treat atelectasis, and ease work of rbeathing

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23
Q

BIPAP - Bi Level Positive Airway Pressure

A

(Pressure Support Ventilation)

NOT a continuous set of pressure - there are 2 pressure settings

Amount og pressure provided changes whether patient is in inspiration or expiration and is indepenently adjusted for each

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24
Q

When does BIPAP deliver higher pressure and lower pressure?

A

Higher Pressure =Inspiration

Lower Pressure = Exhalation

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25
Ventilator
Machines used to assist or completely control ventilation for patients who have an Endotracheal or tracheostomy tube Used in both acute and long term situations
26
How do IPPB and nebulizers differ in hwo they deliver O2/Medication
IPPB is its own machine while Nebulizers hook to the wall
27
What are some indications for supplemental O2
Hypoxemia Hypoxia Dyspnea S/S of Resp. Distress: Dyspnea on exertion, changes in resp. pattern, abnormal ABG, fatigue, LOC changes
28
Hypoxemia
decrease in arterial O2 tension in the blood and is manifested by changes in mental status decreased level of Blood O2
29
Hypoxia
Decrease in O2 supply to the cells and tissues
30
What leads to what: Hypoxemia and Hypoxia
Hypoxemia leads to Hypoxia usually
31
What are 2 problems cased by supplemental oxygen
Hypercapnia Oxygen Toxicity
32
Hypercapnia
High amounts of CO2 in the blood We need the drive to keep breathing though so like in COPD hyperoxygenation can cause loss of drive
33
__ - __% SaO2 for COPD patients
88-92%
34
One easy way to prevent O2 Toxicity
Give the least amount needed and titrate people off it when possible
35
Why is Hypercapnia a problem
High CO2 amounts in the blood --> Becomes normal mechanism for drive the breath We usually rely on hypoxia for resp. drive but if PaO2 is too high we may go into resp. arrest and be unable to breath on our own Similar to COPD
36
Oxygen Toxicity
occurs when adults are given long term percentages of O2 over 50-60% - this O2 in the end causes lung damage and damages lung surfactant
37
S/S Of Oxygen Toxicity
Fibrotic Changes increase capillary congestion Interstitial space thickening Paresthesia Dyspnea Restlessness Pulmonary Edema (Dyspnea, Restlessness, Fatigue, Resp. Distress)
38
What are the 2 treatments for O2 Toxicity
PEEP (Positive End Expiratory Pressure) CPAP (Continuous Positive Airway Pressure) *These reverse or prevent micro-atelectasis which allows a lower % of O2 to be used*
39
What is the best prevention method to prevent O2 toxicity
using lowest amount of O2 needed beforehand
40
What are some other treatments to increase Oxygenation
IS - Incentive Spirometry PT - Chest Physiotherapy Methods
41
How does IS help oxygenation
helps promote the expansion of the alveoli and prevent or treat atelectasis Feedback to the patient about ability to take deep breaths is given Encourage deep inspiration with this
42
What are 3 methods of Chest PT
Postural Drainage Chest Percussion Vibration
43
Postural Drainage (CPT)
Position that uses force of gravity to drain secretions Mobilizes secretions from bottom of the lungs relieves or prevents accumulation of secretions that cause bronchial obstruction
44
Chest Percussion (CPT)
hand clapping to chest wall to loosen secretions cupped hand
45
Vibration (CPT)
device is used to mobilize secretions
46
Rescue Breathing (EMS) Methods
Pocket Mask Ambu Bag/Mask Ambu Bag w/ ET Tube or Trach Tube attachment
47
What are some artificial airways to know of
Endotracheal Tube - ET Tube Tracheostomy Tube
48
Endotracheal Tube
Provides patent airway when simpler methods cannot be used For emergencies Inserted via mouth or nose Tube is cuffed or uncuffed
49
How long can an ET tube be used
NO LONGER THAN 3 WEEKS
50
What is easier to insert an ET tube through the mouth or nose
Orotracheal is easier to insert and it can use a larger tube size making ventilation easier
51
Tracheostomy Tube
Tube inserted into the trachea that is cuffed or uncuffed It provides a patent airway Used in more long term situations It is an artifical opening in the trachea and the tube is inserted into the opening temporary or permanent
52
A tracheostomy tube provides patent airway to...
bypass upper airway obstruction permit long term mechanical ventilation permit oral intake and speech replace an endotracheal tube remove tracheobronchial secretions
53
What situations determine if you use ET tubing or Tracheostomy tubing?
ET is for more emergency situations adn tracheostomy is if the ET tube is in place for more than 14-21 days but needs to be continued
54
What is the placement and process of placement like with endotracheal tubes
It is a flexible tube in many sizes bypassing the upper airway It is placed via laryngoscope into the trachea and a cuff is inflated, taped, or secured with a collar for placement Placement is then confirmed via lung sounds, end tidal CO2 levels and CXR Requires special training to place (anesthesia provider, paramedic, resp therapist, ACLS training provider)
55
What is the placement and process of placement like with tracheostomy tubes?
Semi flexible, rigid or metal tube surgically inserted through an artifical opening made into the trachea at the second or third tracheal ring (trachostomy) Tube has a plate to secure it with sutures or trach ties and comes in multiple sizes
56
An airway tube is positioned 2 cm above...
the carina
57
What are the parts of the tracheostomy tube
outer cannula or main shaft - remains in the trachea inner cannula (disposable or non dispoable) - removed for cleaning or replaced periodically obturator - inserted into tracheostomy during placement and removed once outer cannula is placed
58
What does it mean if a tracheostomy is single cuffed, double cuffed, or uncuffed?
Double cuffed is an alternative form that prevents tracheal damage there are two inflatable cuffs you alternate using
59
What does trachostomy tubes that are fenestrated v not fenestrated mean
the pt can speak if the tube is fenestrated without a speaking valve
60
Advantages of ET Tubes
Keeps airway open Can administer O2 directly to lungs Ability to perform tracheal suctioning Short term therapy - use is < 3 weeks can be attached to a ventilator
61
Advantages of Tracheostomy Tube
Keeps airway open can administer O2 directly to the lungs can perform tracheal suctioning can be used in long term use can attach to ventilator, humidified O2 or Room Air Can permit oral intake and speech (if not on a vent)
62
Disadvantages of ET Tube
discomfort patient cannot speech coughreflex depressed - closure of glottis inhibited secretions thicker - requires suctioning swallowing reflexes depressed risk of aspiration and VAP (Ventilator associated pneumonia) Unintention tube displacement leading to laryngeal swelling, hypoxemia, bradycardia, hypotension, and death requires patient cooperation or restraint use requires special training for nursing staff oral assessment and care needed very frequently
63
Disadvantages of Tracheostomy Tubes
discomfort patient is unable to speak if also on a vent cough reflex depressed secretions tend to be thicker risk of aspiration and VAP unintentional displacement of the tube can be long term used requires special training of nursing staff oral assessment and care needed are frequent
64
What are some complications that can occur from ET tube use
1. tube dislodgement 2. Accidental removal - laryngeal swelling, hypoxemia, bradycardia, hypotension, death 3. High cuff pressure leading to tracheal bleeding, ischemia, or necrosis 4. Low cuff pressure leading to aspiration risk and hypoxia 5. Trauma to tracheal lining 6. VOCAL CORD PARALYSIS
65
What are some potential early complications of tracheostomy tube use
tube dislodgement accidentaly decannulation bleeding pneumothorax air embolism subcutaneous emphysema laryngeal nerve damage posterior tracheal wall penetration
66
What are some later complications of tracheostomy tube use
airway obstruction from secretions infection rupture of innominate artery dysphagia tracheoesophageal fistula tracheal dilation, ischemia, or necrosis
67
What are some important nursing care considerations for a patient with an ET or Trach Tube
Monitor O2 and oxygenation Cuff management maintain patent airway (tube) oral care skin care safety and comfort
68
How should the nurse go about monitoring oxygenation in someone with an ET tube or trach tube
ASSESS FOR S/S OF HYPOEXMIA: This includes changes in mentation, anxiety, dusky skin, dysrhythmias, checking ABGs, and doing continuous SaO2 monitoring
69
What is the Pneumonic for assessing hypoexmia and changes in oxygenation in a patient
"Gee Chap, I Can See Nasty Respirations Too" ``` Grunting Change in LOC Intercostal spaces evident Color (Cyanosis, pallor) Seesaw chest movement Nasal flaring Retration/dysRhythmias Tachypnea ```
70
ET/Trach Tube Cuffs need to be inflated if ...
the patient requires mechanical ventilation the patient is at high risk for aspiration
71
ET/Trach tube cuff pressure should be maintained at ___-___ mmHg and checked every ___-___ Hours
20-25; 6-8
72
Too High Cuff Pressure in the ET/Trach Tube can lead to...
tracheal bleeding ischemia pressure necrosis
73
Too low cuff pressure int he ET/Trach tube can lead to ...
aspiration risk increasing
74
What are some methods of promoting effective airway clearance
chest physiotherapy frequent position changes increased mobility suctioning when indicated
75
Unncessary suctioning can cause...
bronchospasm initiation and cause mechanical trauma to the tracheal mucosa
76
What are the indications to suction an ET/Trach Tube?
Visible secretions in tube Sudden Resp Distress Suspected Aspiration of Secretions Auculstation of adventitious breath sounds over bronchi or trachea Increased resp. rate and sustained coughing sudden or gradual decreases in SpO2 Changes in LOC, restlessness, or tachycardia Cyanosis and Pallor Increased pear airway pressure
77
Should suctioning be done every 1-2 hours?
No there is no rationale to do so The need for suctioning should be assessed every 1-2 hours with assessment and auscultation prior to suctioning Suctioning can clear secretions but can also damage mucosa in the airway and impair cilia action
78
Inline/Closed Suctioning
Allows suctioning WITHOUT disconnection from ventilator Decreases hypoxemia Sustains PEEP Decreases patient anxiety Protection of staff from infections
79
Open Suctioning
A sterile procedure needing sterile gloves Staff must use PPE for splatter fo secretions Higher risk for hypoxia exists here
80
What is Oral and Skin Care like with an ET Tube
1. Brush teeth, gums, tongue, and surface of ET tube x2 daily 2. Rinse pt mouth with an oral rinse 2x daily or as ordered 3. Cleanse mouth every 2-4 hours between brushings wiht oral swab 4. suction oropharyngeal secretions and apply oral moisturizer to lips and mucosa post burshing 5. No mouthwash 6. deep suction every 4 hours * Move tube to other side to prevent pressure injury on the face and skin and rinse debris from oral suction*
81
What is oral and skin care like with a Trach Tube
similar to ET tube until #5 Differs in there needs to be an inner cannula cleanse every 8 hours or more if ordered, stoma and changes and assessment every 8 hours, and change ties or tube holder per order or policy
82
With tubes it is important to do oral care how many times a day at least
2 times a day
83
Ways to prevent complications with an ET/Trach Tube
Administer warm humidified air Maintain appropriate cuff pressure suction prn maintain skin integrity auscultate lung sounds often monitor for s/s of infection administer prescribed O2 and monitor SaO2 Monitor for cyanosis maintain adequate hydration sterile technique for suctioning and trach/Et tube care
84
Pain Control methods with breathing tubes
provide comfort measures provide sedatives or opioid analgesia as ordered
85
Ways to promote communication when a patient has a breathing tube
explain procedures to patient provide paper, erase board, picture boards call bell in reach hearing aid, glasses, etc
86
ET Tubes should be monitored for correct placement how often
every 2-4 hours
87
It is important to confirm what on the ET tube
exit mark
88
On a respiratory assessment of a pt with an ET tube the chest should be doing what
symmetrically expanding
89
With Breathing tubes what should always be available bedside
suction set up and an Ambu bag *with trach tubes inner cannulas and spare tracheostomy of a smaller size should also be available
90
The HOB for ET and Trach tubes should be at what angle
30-45 degrees
91
What is an important consideration for long term tracheostomy placement?
involving patient or family in teaching
92
If an ET or Trach tube is displaced what may need to be done
manually ventilate and call for help
93
Mechanical Ventilation
a positive or negative pressure breathing device that is used to maintain a persons ventilation and O2 delivery for a prolonged period of time comes in many types and brands
94
Ventilator care is a _____ process with ...
collaborative; resp therapist and provider
95
What are some indications for mechanical ventilation
compromised airway severe decrease in Oxygenation altered breathing pattern drug overdose inhalation injury shock multi system failure COPD thoracic or abdominal surgery trauma or lung injury ARDS neuromuscular disorders brain injury or damage rest the respiratory muscles coma PaO2 <50 mmHg with FiO2 >.6 or PaO2 >50 mHg with pH <7.25 vital capacity <2 times tidal volume negative inspiratory force <25 cm H2O resp rate >35 b/min
96
What are the two types of mech. ventilation
1. Negative Pressure (older/"Iron lungs") | 2. Positive Pressure (most common today)
97
Negative Pressure Ventilation
Exerts negative pressure on the external chest- EXTERNAL FORCE Decreases intrathoracic pressure during inspiration adn allows air to flow into the lungs simple to use, does not need intubation, adaptable for home use
98
Negative Pressure Ventilation is similar to ___ ___
spontaneous respiration
99
Negative Pressure Ventilation is commonly used in what situation still?
chronic respiratory failure - neuromuscular conditions like poliomyelitis, MD, ALS, myasthenia gravis
100
Positive Pressure Ventilation
4 types Exerts positive pressure on the airway - it pushes air into the lungs which causes the alveoli to expand during inspiration used in acute care, OR, or at home
101
What is inspiration/exhalation like during positive pressure ventilation
During inspiration, air is pushed into the lung under positive pressure Intrathoracic pressure is RAISED during lung inflation (unlike normal inspiration) Patient exhales passively
102
Positive Pressure ventilation is commonly used alongside what
an ET or Trach tube
103
4 types of Positive Pressure Ventilation
Volume Cycled Vents Pressure Cycled Vents High frequency oscillatory support ventilators NIPPV - noninvasive positive pressure ventilation
104
Volume Cycled Ventilators
Pos pressure vent delivers preset volume of O2 with each inspiration airway pressure varies on patient need exhalation is passive
105
Disadvantage of Volume Cycled Ventilators
possibility of barotrauma which can lead to damage of alveolar capillary membrane and cause air leaks into surrounding tissue
106
Pressure Cycled Ventilators
delivers present pressure of air on each inspiration pos pressure vent volume of air/o2 varies on pt resistance or compliance
107
Disadvantage of Pressure Cycled Ventilation
inconsistent tidal volume can occur which compromises ventilation
108
High Frequency Oscillatory Support Ventilators (HFOSV)
Pos Pressure Vent Causes high resp rates (180-900 breaths/min) with low tidal volume and high airway pressure
109
When are high frequency oscillatory support vents usually used
To open alveoli and in small airway issues like atelectasis and ARDS thought is also that it helps protect the lungs from injury
110
Noninvasive Positive Pressure Ventilation (NIPPV)
Pos Pressure Vent Elimites the need for ET tube or trach tube 3 kinds Pressure controlled ventilation with pressure support
111
What is thought to decrease with NIPPV use and why?
decreased risk of pneumonia since there are no tubes
112
What sort of patients may get NIPPV
Acute or chronic resp failure COPD CHF acute pulmonary edema sleep related breathing disorders OSA end of life care for those who do not want to be trached/tubed
113
What are the 3 types of NIPPV
PEEP - Positive end expiratory pressure CPAP - continuous positive airway pressure BiPAP - bilevel positive airway pressure
114
PEEP
positive end expiratory pressure - a type of NIPPV Positive pressure occurs during exhalation
115
PEEP is useful in ...
pulmonary edema
116
When should caution be used with PEEP
in those with COPD or decreased CO
117
CPAP
continuous positive airway pressure - a type of NIPPV Air delivered continuously during spontaneous breathing
118
CPAP is good for...
sleep apnea
119
BiPAP
Bilevel positive airway pressure - a type of NIPPV noninvasive method where pressure is based on the rate of inhalation and exhalation
120
BiPAP can help prevent...
reintubation needs after extubation
121
BiPAP is okay for patients in...
COPD, heart failure, and sleep apnea
122
Nursing Interventions for Mechanical Ventilation with an Airway Tube (ET/Trach)
Assess Setting Assessment and Troubleshooting Alarms Maintenance of airway and pt safety
123
What are some ways to maintain the airway and pt safety of a patient on a mechanical vent with a tube
suctioning of patient restraints if needed and when needed excess water in the system timely change of disposable components
124
What are the 5 important ventilatory settings
Mode Tidal Volume FiO2 Rate PEEP
125
How does Tidal Volume settings vary
based on pt size and age tidal volume is the amount of air going in and out with each insp/exp
126
What is the standard ventilator rate
12-20 BPM * can vary by pt age and condition
127
What is FiO2
the % of O2 given to a patient
128
When is the PEEP setting used on the ventilator
When O2 Sat is high and should be decreased It usually is measured in 5-15 cm of pressure
129
What are the 6 ventilator modes going from most control over patient breathing (invasive) to minimal ventilator input (non-invasive)
CMV - Controlled Mechanical Ventilation *most invasive* A/C Ventilation - Continuous Mandatory Ventalation aka Assist Control IMV - Intermittent Mandatory Ventilation SIMV - Synchronized Intermittent Mandatory Ventilation PSV - Pressure Support Ventilation APRV - Airway Pressure Release Ventilation *least invasive)
130
CMV Mode
Controlled Mechanical Ventilation Mode Most INvasive Used for clients who cannot initiate ANY spon. respirations it is the lead used as it doesn no allow for any client initiated breaths It will deliver a total set tidal volume at a set rate to the pt.
131
AC Vent Mode
Continuous Mandatory Ventilation AKA Assist Control Ventilation Mode 2nd most invasive Machine can respond to clients own breath - but those breaths are assisted Ventilator delivers a set tidal volume OR pressure and a set rate
132
What is the msot common ventilatory mode
AC Mode
133
SIMV mode
Synchronized intermittent mandatory ventilation mode 4th most invasive can be a primary mode or weaning mode Like AC, but lets the client breath spon. at their own rate and at a tidal volume between ventilator breaths Also similar to IMV but it senses spontaneous breaths and will not deliver a breath during an exhale delivers a set tidal volume and has a set rate (for machine assisted breaths taken)
134
What is the benefit of SIMV over IMV Mode
it will not try to deliver a breath during exhalation / fight the ventilator it allows spontaneous breaths when detected and will administer as needed
135
IMV Mode
Intemrittent Mandatory Ventilation - can be used as a primary mode or weaning mode 3rd most invasive mode Similar to AC but allows client to breath spontaneously at their own rate and tidal volume between vent breaths vent delivers a set tidal volume at a set rate for machine assisted breaths
136
What is the issue with IMV mode
spontaneous breaths ar enot machine assisted or sensed which can lead to fighting/bucking the ventilator a patient could be trying to exhale while the machien delivers a breath
137
What is the benefit of IMV over AC
allows the pt to use their own muscles for ventilation
138
When assessing "Sync" on IMV or SIMV mode what does this mean?
Does the pt seem synchronous with the vent, breathing easy? or are they fighting it?
139
What is "bucking"
attemting to breathe on your own with IMV, and now allowing ventilator to deliver breaths - fighting the vent
140
Things to monitor on IMV and SIMV vents
resp rate minute volume spon machine generated TV FiO2 ABGs
141
PSV Mode
pressure support ventilation least invasive completely relies on spon breaths - provides a constant pressure to the patients own breaths and the tidal volume and rate is based on the patient's own
142
When assessing a patient on PSV mode what may need to be checked and changed
Rate and Tidal Volume should be assessed and pressure may need to be changed to avoid tachypnea and large tidal volumes
143
APRV Mode
Airway pressure release ventilation is pressure limited and a time triggered mode - gives cont. positive airway rpessure either high or low and two levels of inspiratory time as high or low there are then time triggered mandatory breaths delivered by the machine but pt can take spon breaths the tidal volume is pt driven
144
When is APRV good for
APneic Episodes as it delivers a breath for the patient when needed Also for improving oxygenation and treating refractory hypoxemia in acute lung injuries, ARDS, and severe atelectasis
145
What to do when a ventilatory alarm goes off
ALWAYS ASSES PATIENT FIRST, then the alarm! Do not ignore it do not turn it off - and when in doubt call the resp. therapist for consultation However, some alarms need to be addressed yourself
146
When an alarm goes off and when in doubt...
bag the patient and call respiratory STAT
147
What are some reasons ALARMs on vents may go off
High pressure Low Pressure Temperature Apnea
148
What is a high pressure alarm caused by
increased airway secretions, bronchospasm, displaced or obstructed tube, water in tubes, stiff airway (ARDS) and kinked tubing
149
What is a low pressure alarm caused by
usually a disconnection or leak in the system
150
What does an apnea alarm mean
the patient is off the ventilator or tubing disconnected from the pateint
151
What does a temperature alarm mean
usually needs more water for humidification
152
What is important aspects of nursing documentaiton to include for ventilated patients
Mode Used Tidal Volume (usually 6-10 L/kg) Rate (12-16) FiO2 (Percent O2) Amount of PEEP (if ussed) Pressure Support (If Used) Sputum - amount, frequency, color Patient tolerance to vent and suctioning
153
Risks associated with mechanical ventilation
Infection - Ventilator Acquired Pneumonia Pneumothorax Lung Damage SE of sedation and paralytic medications - may need sedation vacation Maintenance of life when not wanted Hypotension sodium and water imbalance Gi system issues
154
What about ventilators causes hypotension
increased positive pressure increasing the itnrathoracic pressure which inhibits blood return to the heart
155
What sort of GI system issues occur with ventilators
Usually due to the fact they are bedbound: Stress Ulcers + GI Bleeding (Need peptic ulcer prophylaxis) Decreased peristalsis
156
Sodium and Water Imbalance from Mechanical Ventilation
progressive fluid retention after 48-72 hours of positive pressure ventilation can occur leading to decreased UO and increased Na+
157
Nutritional Issues while on a Ventilator
Hypermetabolism from critical illness Elimination of normal route for eating Inadequate nutrition puts eprson at risk for Poor oxygen transport secondary to anemia and poor exercise (bedbound) Decreased total protein and albumin delays O2 weaning decreased response to infection increased risk for stress ulcer *OVERALL BODY DECONDITIONING IS OCCURRING*
158
What is a possible intervention for nutritional issues on ventilators?
Orogastric/Nasogastric/PEG Tube - however there are then issues associated with enteral feeding tubes
159
Overall, What are the most important nursing interventions for clients on ventilators/breathing assistance
Maintaining a Patent Airway Monitoring and documenting vent settings hourly - rate, FiO2, tidal volume, mode of ventilation, alarm settings Maintaining proper cuff pressure Administering meds as needed (analgesics to relieve pain and boost gas exchange, sedatives, ulcer preventing agents, neuromuscular blocking agents) Good Communication Good Nutrition Monitoring the Weaning Process
160
What ar ethe 3 stages of mechanical vent weaning process
1. Gradual removal from the vent 2. removal of ET or trach tube 3. removal of O2
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What stance is the decisiont to begin the weaning process made from
a physiological standpoint not a mechanical stand point
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When does the weaning process begin
the earliest time possible when it is safe for the patient
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What things needs to be looked at to start the weaning process
Hemodynamically and physiologically stable - Stable, ABGs stable Spontaneous breathing occurring Recovered from acute stage medical or surgical issues cause of resp failure is reveresed
164
The weaning process required what among the primary nurse, primary provider, and resp therapist
collaboration
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Never do what during the weaning process
1. Never abruptly remove the patient from the ventilator | 2. Never do weaning at night
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Ways to facilitate weaning process
decrease resp rate setting give short times off vent or with 0 rate may place T piece or briggs on assess for resp distress or cardiac compromise educate pt and family prep patient physiologically explain potential SOB normal to an extent Monitor O2 status, pulse ox, EKG, and resp pattern
167
It is important to acknolwedge what potential psychological issue regrading vent weaning
the patient may have developed a psychological dependence on the ventilator and have anxiety regarding weaning
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The weaning process will look...
different a little with each patient
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Successful weaning is supplemented with...
intensive pulmonary care
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What may gradual decrease of ventilators control over patient breathing look like wiht the settings
CMV w/ PEEP --> CMV without PEEP --> AC with PEEP --> AC without PEEP --> IMV with PEEP --> IMV without PEEP --> SIMV --> Briggs adaptor/T piece or trach collar/mask
171
How long does it take before extubation fo ET tubes can occur post mech. vent
can take days to weeks depending on long intubation if short intubation only takes 2-3 hours before they can be removed
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Removal of the ET tube can occur when the patient can...
breath spon cough up own secretions swallow move jaw decrease tracheostomy size (completed by provider)
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Removal of a tracheostomy can occur when the patient can
breath spon cough up own secretions swallow move the jaw
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What is the removal of tracheostomy process like
Pt has adequate secretion clearance --> Move to trial period of mouth and nose breathing Change to fenestrated tube, decrease stoma size, and switch to smaller button (provider does this) finally, once pt can maintain airway tube is removed and occlusive dressing is placed over the stoma for closure
175
What is one of the msot common nosocomial infections
VAP -Ventilator Acquired Pneumonia
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What is the leading cause of death from nosocomial infectiosn
VAP
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When does VAP usually occur
48 hours or more after mechanical ventilation with intubation (can also occur if they have a treacheostomy)
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VAP is associated with what results?
longer hospital stays and increased mortality rates
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Risk Factors for VAP
poor oral hygeine - we need to help contaminated resp equipment - use new clean stuff and sterile while suctioning poor hand hygiene decreased ability of patient to cough and clear secretions immobility patient age and comorbidities reintubation depressed consciousness paralysis
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What is the VAP Bundle
A group of interventions to provide a standardized method of care based on EBP for VAP: 1. HOB 30-45 degrees 2. Daily sedation vacations to see if tube can get out ASAP 3. Peptic Ulcer disease prevention 4. Deep vein thrombosis prevention 5. Oral care daily with chlorhexidine gluconate .12% oral rinse
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What are some ways to prevent VAP
VAP Bundle (5 things) Effective handwashing before and after suctioning, when vent equipment is touched and when in contact with resp secretions wear gloves when in contact wiht the patient maintain ET tube cuff pressure prevent condensationa nd subglottic drainage that collects in vent tubing -drain it gastric volume monitoring - prevent aspiration