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N362: Practice of Nursing III > Week 9: Mechanical Ventilation - Start of Exam 3 > Flashcards

Week 9: Mechanical Ventilation - Start of Exam 3 Flashcards

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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
Q

Ventilator

A

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

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26
Q

How do IPPB and nebulizers differ in hwo they deliver O2/Medication

A

IPPB is its own machine while Nebulizers hook to the wall

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27
Q

What are some indications for supplemental O2

A

Hypoxemia

Hypoxia

Dyspnea

S/S of Resp. Distress: Dyspnea on exertion, changes in resp. pattern, abnormal ABG, fatigue, LOC changes

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28
Q

Hypoxemia

A

decrease in arterial O2 tension in the blood and is manifested by changes in mental status

decreased level of Blood O2

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29
Q

Hypoxia

A

Decrease in O2 supply to the cells and tissues

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30
Q

What leads to what: Hypoxemia and Hypoxia

A

Hypoxemia leads to Hypoxia usually

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31
Q

What are 2 problems cased by supplemental oxygen

A

Hypercapnia

Oxygen Toxicity

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32
Q

Hypercapnia

A

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

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33
Q

__ - __% SaO2 for COPD patients

A

88-92%

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34
Q

One easy way to prevent O2 Toxicity

A

Give the least amount needed and titrate people off it when possible

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35
Q

Why is Hypercapnia a problem

A

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

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36
Q

Oxygen Toxicity

A

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

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37
Q

S/S Of Oxygen Toxicity

A

Fibrotic Changes

increase capillary congestion

Interstitial space thickening

Paresthesia

Dyspnea

Restlessness

Pulmonary Edema (Dyspnea, Restlessness, Fatigue, Resp. Distress)

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38
Q

What are the 2 treatments for O2 Toxicity

A

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

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39
Q

What is the best prevention method to prevent O2 toxicity

A

using lowest amount of O2 needed beforehand

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40
Q

What are some other treatments to increase Oxygenation

A

IS - Incentive Spirometry

PT - Chest Physiotherapy Methods

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41
Q

How does IS help oxygenation

A

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

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42
Q

What are 3 methods of Chest PT

A

Postural Drainage

Chest Percussion

Vibration

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43
Q

Postural Drainage (CPT)

A

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

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44
Q

Chest Percussion (CPT)

A

hand clapping to chest wall to loosen secretions

cupped hand

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45
Q

Vibration (CPT)

A

device is used to mobilize secretions

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46
Q

Rescue Breathing (EMS) Methods

A

Pocket Mask

Ambu Bag/Mask

Ambu Bag w/ ET Tube or Trach Tube attachment

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47
Q

What are some artificial airways to know of

A

Endotracheal Tube - ET Tube

Tracheostomy Tube

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48
Q

Endotracheal Tube

A

Provides patent airway when simpler methods cannot be used

For emergencies

Inserted via mouth or nose

Tube is cuffed or uncuffed

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49
Q

How long can an ET tube be used

A

NO LONGER THAN 3 WEEKS

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50
Q

What is easier to insert an ET tube through the mouth or nose

A

Orotracheal is easier to insert and it can use a larger tube size making ventilation easier

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51
Q

Tracheostomy Tube

A

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

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52
Q

A tracheostomy tube provides patent airway to…

A

bypass upper airway obstruction

permit long term mechanical ventilation

permit oral intake and speech

replace an endotracheal tube

remove tracheobronchial secretions

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53
Q

What situations determine if you use ET tubing or Tracheostomy tubing?

A

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

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54
Q

What is the placement and process of placement like with endotracheal tubes

A

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)

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55
Q

What is the placement and process of placement like with tracheostomy tubes?

A

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

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56
Q

An airway tube is positioned 2 cm above…

A

the carina

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57
Q

What are the parts of the tracheostomy tube

A

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

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58
Q

What does it mean if a tracheostomy is single cuffed, double cuffed, or uncuffed?

A

Double cuffed is an alternative form that prevents tracheal damage

there are two inflatable cuffs you alternate using

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59
Q

What does trachostomy tubes that are fenestrated v not fenestrated mean

A

the pt can speak if the tube is fenestrated without a speaking valve

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60
Q

Advantages of ET Tubes

A

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

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61
Q

Advantages of Tracheostomy Tube

A

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)

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62
Q

Disadvantages of ET Tube

A

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

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63
Q

Disadvantages of Tracheostomy Tubes

A

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

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64
Q

What are some complications that can occur from ET tube use

A
  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
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65
Q

What are some potential early complications of tracheostomy tube use

A

tube dislodgement

accidentaly decannulation

bleeding

pneumothorax

air embolism

subcutaneous emphysema

laryngeal nerve damage

posterior tracheal wall penetration

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66
Q

What are some later complications of tracheostomy tube use

A

airway obstruction from secretions

infection

rupture of innominate artery

dysphagia

tracheoesophageal fistula

tracheal dilation, ischemia, or necrosis

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67
Q

What are some important nursing care considerations for a patient with an ET or Trach Tube

A

Monitor O2 and oxygenation

Cuff management

maintain patent airway (tube)

oral care

skin care

safety and comfort

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68
Q

How should the nurse go about monitoring oxygenation in someone with an ET tube or trach tube

A

ASSESS FOR S/S OF HYPOEXMIA:

This includes changes in mentation, anxiety, dusky skin, dysrhythmias, checking ABGs, and doing continuous SaO2 monitoring

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69
Q

What is the Pneumonic for assessing hypoexmia and changes in oxygenation in a patient

A

“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

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70
Q

ET/Trach Tube Cuffs need to be inflated if …

A

the patient requires mechanical ventilation

the patient is at high risk for aspiration

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71
Q

ET/Trach tube cuff pressure should be maintained at ___-___ mmHg and checked every ___-___ Hours

A

20-25; 6-8

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72
Q

Too High Cuff Pressure in the ET/Trach Tube can lead to…

A

tracheal bleeding

ischemia

pressure necrosis

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73
Q

Too low cuff pressure int he ET/Trach tube can lead to …

A

aspiration risk increasing

74
Q

What are some methods of promoting effective airway clearance

A

chest physiotherapy

frequent position changes

increased mobility

suctioning when indicated

75
Q

Unncessary suctioning can cause…

A

bronchospasm initiation and cause mechanical trauma to the tracheal mucosa

76
Q

What are the indications to suction an ET/Trach Tube?

A

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
Q

Should suctioning be done every 1-2 hours?

A

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
Q

Inline/Closed Suctioning

A

Allows suctioning WITHOUT disconnection from ventilator

Decreases hypoxemia

Sustains PEEP

Decreases patient anxiety

Protection of staff from infections

79
Q

Open Suctioning

A

A sterile procedure needing sterile gloves

Staff must use PPE for splatter fo secretions

Higher risk for hypoxia exists here

80
Q

What is Oral and Skin Care like with an ET Tube

A
  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

  1. suction oropharyngeal secretions and apply oral moisturizer to lips and mucosa post burshing

5.No mouthwash

  1. 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
Q

What is oral and skin care like with a Trach Tube

A

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
Q

With tubes it is important to do oral care how many times a day at least

A

2 times a day

83
Q

Ways to prevent complications with an ET/Trach Tube

A

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
Q

Pain Control methods with breathing tubes

A

provide comfort measures

provide sedatives or opioid analgesia as ordered

85
Q

Ways to promote communication when a patient has a breathing tube

A

explain procedures to patient

provide paper, erase board, picture boards

call bell in reach

hearing aid, glasses, etc

86
Q

ET Tubes should be monitored for correct placement how often

A

every 2-4 hours

87
Q

It is important to confirm what on the ET tube

A

exit mark

88
Q

On a respiratory assessment of a pt with an ET tube the chest should be doing what

A

symmetrically expanding

89
Q

With Breathing tubes what should always be available bedside

A

suction set up and an Ambu bag

*with trach tubes inner cannulas and spare tracheostomy of a smaller size should also be available

90
Q

The HOB for ET and Trach tubes should be at what angle

A

30-45 degrees

91
Q

What is an important consideration for long term tracheostomy placement?

A

involving patient or family in teaching

92
Q

If an ET or Trach tube is displaced what may need to be done

A

manually ventilate and call for help

93
Q

Mechanical Ventilation

A

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
Q

Ventilator care is a _____ process with …

A

collaborative; resp therapist and provider

95
Q

What are some indications for mechanical ventilation

A

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
Q

What are the two types of mech. ventilation

A
  1. Negative Pressure (older/”Iron lungs”)
  2. Positive Pressure (most common today)
97
Q

Negative Pressure Ventilation

A

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
Q

Negative Pressure Ventilation is similar to ___ ___

A

spontaneous respiration

99
Q

Negative Pressure Ventilation is commonly used in what situation still?

A

chronic respiratory failure - neuromuscular conditions like poliomyelitis, MD, ALS, myasthenia gravis

100
Q

Positive Pressure Ventilation

A

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
Q

What is inspiration/exhalation like during positive pressure ventilation

A

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
Q

Positive Pressure ventilation is commonly used alongside what

A

an ET or Trach tube

103
Q

4 types of Positive Pressure Ventilation

A

Volume Cycled Vents

Pressure Cycled Vents

High frequency oscillatory support ventilators

NIPPV - noninvasive positive pressure ventilation

104
Q

Volume Cycled Ventilators

A

Pos pressure vent

delivers preset volume of O2 with each inspiration

airway pressure varies on patient need

exhalation is passive

105
Q

Disadvantage of Volume Cycled Ventilators

A

possibility of barotrauma which can lead to damage of alveolar capillary membrane and cause air leaks into surrounding tissue

106
Q

Pressure Cycled Ventilators

A

delivers present pressure of air on each inspiration

pos pressure vent

volume of air/o2 varies on pt resistance or compliance

107
Q

Disadvantage of Pressure Cycled Ventilation

A

inconsistent tidal volume can occur which compromises ventilation

108
Q

High Frequency Oscillatory Support Ventilators (HFOSV)

A

Pos Pressure Vent

Causes high resp rates (180-900 breaths/min) with low tidal volume and high airway pressure

109
Q

When are high frequency oscillatory support vents usually used

A

To open alveoli and in small airway issues like atelectasis and ARDS

thought is also that it helps protect the lungs from injury

110
Q

Noninvasive Positive Pressure Ventilation (NIPPV)

A

Pos Pressure Vent

Elimites the need for ET tube or trach tube

3 kinds

Pressure controlled ventilation with pressure support

111
Q

What is thought to decrease with NIPPV use and why?

A

decreased risk of pneumonia since there are no tubes

112
Q

What sort of patients may get NIPPV

A

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
Q

What are the 3 types of NIPPV

A

PEEP - Positive end expiratory pressure

CPAP - continuous positive airway pressure

BiPAP - bilevel positive airway pressure

114
Q

PEEP

A

positive end expiratory pressure - a type of NIPPV

Positive pressure occurs during exhalation

115
Q

PEEP is useful in …

A

pulmonary edema

116
Q

When should caution be used with PEEP

A

in those with COPD or decreased CO

117
Q

CPAP

A

continuous positive airway pressure - a type of NIPPV

Air delivered continuously during spontaneous breathing

118
Q

CPAP is good for…

A

sleep apnea

119
Q

BiPAP

A

Bilevel positive airway pressure - a type of NIPPV

noninvasive method where pressure is based on the rate of inhalation and exhalation

120
Q

BiPAP can help prevent…

A

reintubation needs after extubation

121
Q

BiPAP is okay for patients in…

A

COPD, heart failure, and sleep apnea

122
Q

Nursing Interventions for Mechanical Ventilation with an Airway Tube (ET/Trach)

A

Assess Setting

Assessment and Troubleshooting Alarms

Maintenance of airway and pt safety

123
Q

What are some ways to maintain the airway and pt safety of a patient on a mechanical vent with a tube

A

suctioning of patient

restraints if needed and when needed

excess water in the system

timely change of disposable components

124
Q

What are the 5 important ventilatory settings

A

Mode

Tidal Volume

FiO2

Rate

PEEP

125
Q

How does Tidal Volume settings vary

A

based on pt size and age

tidal volume is the amount of air going in and out with each insp/exp

126
Q

What is the standard ventilator rate

A

12-20 BPM

  • can vary by pt age and condition
127
Q

What is FiO2

A

the % of O2 given to a patient

128
Q

When is the PEEP setting used on the ventilator

A

When O2 Sat is high and should be decreased

It usually is measured in 5-15 cm of pressure

129
Q

What are the 6 ventilator modes going from most control over patient breathing (invasive) to minimal ventilator input (non-invasive)

A

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
Q

CMV Mode

A

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
Q

AC Vent Mode

A

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
Q

What is the msot common ventilatory mode

A

AC Mode

133
Q

SIMV mode

A

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
Q

What is the benefit of SIMV over IMV Mode

A

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
Q

IMV Mode

A

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
Q

What is the issue with IMV mode

A

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
Q

What is the benefit of IMV over AC

A

allows the pt to use their own muscles for ventilation

138
Q

When assessing “Sync” on IMV or SIMV mode what does this mean?

A

Does the pt seem synchronous with the vent, breathing easy? or are they fighting it?

139
Q

What is “bucking”

A

attemting to breathe on your own with IMV, and now allowing ventilator to deliver breaths - fighting the vent

140
Q

Things to monitor on IMV and SIMV vents

A

resp rate

minute volume

spon machine generated TV

FiO2

ABGs

141
Q

PSV Mode

A

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
Q

When assessing a patient on PSV mode what may need to be checked and changed

A

Rate and Tidal Volume should be assessed and pressure may need to be changed to avoid tachypnea and large tidal volumes

143
Q

APRV Mode

A

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
Q

When is APRV good for

A

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
Q

What to do when a ventilatory alarm goes off

A

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
Q

When an alarm goes off and when in doubt…

A

bag the patient and call respiratory STAT

147
Q

What are some reasons ALARMs on vents may go off

A

High pressure

Low Pressure

Temperature

Apnea

148
Q

What is a high pressure alarm caused by

A

increased airway secretions, bronchospasm, displaced or obstructed tube, water in tubes, stiff airway (ARDS) and kinked tubing

149
Q

What is a low pressure alarm caused by

A

usually a disconnection or leak in the system

150
Q

What does an apnea alarm mean

A

the patient is off the ventilator or tubing disconnected from the pateint

151
Q

What does a temperature alarm mean

A

usually needs more water for humidification

152
Q

What is important aspects of nursing documentaiton to include for ventilated patients

A

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
Q

Risks associated with mechanical ventilation

A

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
Q

What about ventilators causes hypotension

A

increased positive pressure increasing the itnrathoracic pressure which inhibits blood return to the heart

155
Q

What sort of GI system issues occur with ventilators

A

Usually due to the fact they are bedbound:

Stress Ulcers + GI Bleeding (Need peptic ulcer prophylaxis)

Decreased peristalsis

156
Q

Sodium and Water Imbalance from Mechanical Ventilation

A

progressive fluid retention after 48-72 hours of positive pressure ventilation can occur leading to decreased UO and increased Na+

157
Q

Nutritional Issues while on a Ventilator

A

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
Q

What is a possible intervention for nutritional issues on ventilators?

A

Orogastric/Nasogastric/PEG Tube - however there are then issues associated with enteral feeding tubes

159
Q

Overall, What are the most important nursing interventions for clients on ventilators/breathing assistance

A

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
Q

What ar ethe 3 stages of mechanical vent weaning process

A
  1. Gradual removal from the vent
  2. removal of ET or trach tube
  3. removal of O2
161
Q

What stance is the decisiont to begin the weaning process made from

A

a physiological standpoint not a mechanical stand point

162
Q

When does the weaning process begin

A

the earliest time possible when it is safe for the patient

163
Q

What things needs to be looked at to start the weaning process

A

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
Q

The weaning process required what among the primary nurse, primary provider, and resp therapist

A

collaboration

165
Q

Never do what during the weaning process

A
  1. Never abruptly remove the patient from the ventilator
  2. Never do weaning at night
166
Q

Ways to facilitate weaning process

A

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
Q

It is important to acknolwedge what potential psychological issue regrading vent weaning

A

the patient may have developed a psychological dependence on the ventilator and have anxiety regarding weaning

168
Q

The weaning process will look…

A

different a little with each patient

169
Q

Successful weaning is supplemented with…

A

intensive pulmonary care

170
Q

What may gradual decrease of ventilators control over patient breathing look like wiht the settings

A

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
Q

How long does it take before extubation fo ET tubes can occur post mech. vent

A

can take days to weeks depending on long intubation

if short intubation only takes 2-3 hours before they can be removed

172
Q

Removal of the ET tube can occur when the patient can…

A

breath spon

cough up own secretions

swallow

move jaw

decrease tracheostomy size (completed by provider)

173
Q

Removal of a tracheostomy can occur when the patient can

A

breath spon

cough up own secretions

swallow

move the jaw

174
Q

What is the removal of tracheostomy process like

A

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
Q

What is one of the msot common nosocomial infections

A

VAP -Ventilator Acquired Pneumonia

176
Q

What is the leading cause of death from nosocomial infectiosn

A

VAP

177
Q

When does VAP usually occur

A

48 hours or more after mechanical ventilation with intubation (can also occur if they have a treacheostomy)

178
Q

VAP is associated with what results?

A

longer hospital stays and increased mortality rates

179
Q

Risk Factors for VAP

A

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

180
Q

What is the VAP Bundle

A

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
181
Q

What are some ways to prevent VAP

A

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

N362: Practice of Nursing III (15 decks)

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