1
Q
What is Tidal volume?
A
The volume of air inhaled and exhaled with each breath
2
Q
What is Inspiratory reserve volume ?
A
The maximum volume of air that can be inhaled after a normal inhalation
3
Q
What is Expiratory reserve volume ?
A
he maximum volume of air that can be exhaled forcibly after a normal exhalation
4
Q
What is Residual volume ?
A
The volume of air remaining in the lungs after a maximum exhalation
5
Q
What is Vital capacity ?
A
The maximum volume of air exhaled from the point of maximum inspiration: VC = TV + IRV + ERV
6
Q
What is Inspiratory capacity ?
A
The maximum volume of air inhaled after normal expiration: IC = TV + IRV
7
Q
What is Functional residual capacity ?
A
The volume of air remaining in the lungs after a normal expiration: FRC = ERV + RV
8
Q
What is total lung capacity?
A
The volume of air in the lungs after a maximum inspiration TLC = TV + IRV + ERV + RV
9
Q
True / False
Tidal Volume can significantly vary in the event of disease in the pulmonary system.
A
False.
The tidal volume may not vary, even with severe disease.
10
Q
When may the expiratory reserve volume decrease?
A
Expiratory reserve volume is decreased with restrictive conditions, such as obesity, ascites, pregnancy.
11
Q
When may Residual volume be increased ?
A
Residual volume may be increased with obstructive disease.
12
Q
A decrease in vital capacity may be found in :
A
neuromuscular disease,
generalized fatigue,
atelectasis,
pulmonary edema,
COPD,
obesity.
13
Q
A decrease in inspiratory capacity may indicate :
A
A restrictive disease. It may also be decreased in obesity.
14
Q
Functional residual capacity may be increased with :
A
COPD and decreased in ARDS and obesity
15
Q
Total lung capacity may be decreased with :
A
restrictive disease such as atelectasis and pneumonia and increased in COPD.
16
Q
What are the pulmonary function tests that we can do?
A
Arterial blood gases
Venous blood gas studies
Pulse oximetry
End-tidal carbon dioxide
Cultures
Sputum studies
Imaging studies
17
Q
Which pulmonary function test do we perform in patient w/ an Endotracheal tube?
A
End-tidal carbon dioxide - we use this test to ensure that the tube is placed correctly
18
Q
What is Atelectasis?
A
Closure or collapse of alveoli - this interfere w/ the perfusion of oxygen in the lungs.
19
Q
What is the most common cause of Atelectasis?
A
Not taking a deep breath after surgery & post- op immobility
Nurses should observe and monitor how patients are breathing after they’re coming out of surgery.
s&s they are shallow breaths, could be due to pain.
20
Q
After surgery, use of what should be stressed to our patients?
A
Incentive spirometry.
21
Q
What are some other things (apart from post-surgery) that may cause Atelectasis?
A
- Hypoventilation
- Obstruction
- Compression
22
Q
what are s&s of acute Atelectasis?
A
tachycardia,
tachypnea,
pleural pain, and central cyanosis if large areas of the lung are affected (blue lips and nail beds)
23
Q
what are s&s of chronic Atelectasis?
A
similar to acute, pulmonary infection may be present
24
Q
How do we assess for Atelectasis?
A
- increased WOB and hypoxemia
- Decreased lung sounds and crackles over affected area (bases of lungs)
- CXR may suggest a diagnosis of atelectasis before clinical symptoms appear
- Pulse ox low saturation of hemoglobin w/ oxygen <90%
25
What should we educate our patients on after they come out of surgery?
* To deep breaths if they cannot walk
* Frequent short walks if they're able
* If pulse ox < 90% we will instruct patients to take deep breaths in an attempt to prevent atelectasis.
26
What are ways that we can prevent Atelectasis in our patients?
* Frequent turning
* Early mobilization - its hard to expand lungs fully in bed.
* Strategies to expand lungs and manage secretions
* Incentive spirometer ( 10 x per/hr)
* Voluntary deep breathing
* Secretion management
* Pressurized metered-dose inhaler
27
Atelectasis can rapidly progress to ___________.
Pneumonia. This is because secretions and bacteria are sitting in the lungs.
This can quickly turn into respiratory failure.
28
What are the first line measures in managing Atelectasis?
* Improve ventilation & remove secretions
Frequent turning Q2H,
Early ambulation (sooner the better) ,
Lung volume expansion maneuvers (incentive spirometer) and coughing
Explain to our patient the importance of doing this to prevent pneumonia.
29
What are second line measures once the patients Atelectasis is developing/worsening ?
* Oral care/ Brush teeth if on ventilator (prevent pneumonia)
* Out of the bed at least 3 times per day if possible
* Elevate head of bed
30
What are the components of ICOUGH?
*Incentive spirometry
*Coughing and deep breathing
*Oral care (brushing teeth and using mouthwash twice a day)
*Understanding (patient and staff education)
*Getting out of bed at least three times daily
*Head-of-bed elevation
This helps open airways.
31
What are more invasive measures that we can do for patients whose atelectasis has progressed where its severely affecting ventilation (collapse of alveoli) ?
* CPAP/BiPap, bronchoscopy - continuous positive airways pressure
* CPT - Continuous positive airway pressure w/ mask
* Endotracheal intubation and mechanical ventilation (PEEP)
* Thoracentesis to relieve compression / fluid - this will help w/ perfusion.
32
What does PEEP stand for? What does it do?
Positive End-Expiratory Pressure
Keeps airways and the small lung spaces open to allow for adequate oxygenation when a person cannot breathe on their own.
It's a respiratory setting for the ventilators.
33
True / False
COVID -19 is a consideration for acute respiratory failure.
True
34
Since there is no cure for COVID, what should we do with our patients who are having severe symptoms?
* Isolate to prevent transmission
* Hydration
* Allow for rest.
(supportive therapy)
35
What interventions can be done by nurses to prevent decompensation of patients w/ COVID-19 ?
* Continuous pulse oximetry
* Early supplemental oxygen
* Awake proning - Improves oxygenation and prevents alveolar collapse
* Frequent respiratory assessments
* Monitor RR, work of breathing, ability to speak, mental status
* Early escalation of care
36
What does COVID-19 increase the risk ok?
* Pneumonia
* Venous thromboembolism
* shock and respiratory failure.
37
what are the s&s of COVID 19
Ranges from asymptomatic to severe pneumonia.
* Fatigue,
* mild to severe pneumonia like symptoms
* myalgia,
* congestion,
* sore throat,
* diarrhea,
* anosmia - loss of smell
* ageusia - loss of taste
* Can progress to respiratory failure or ARDS (Acute respiratory distress syndrome)
* multisystem organ failure
38
What isolation precautions do we have with COVID?
Depends on the facility. May be droplet or airborne precautions.
39
What are the risk factors associated with COVID?
* Advanced age - higher mortality > 80 y.o
* Medical comorbidities : cancer, chronic conditions, obesity, smoking, HTN
* Sex - men more impacted than women
* Socioeconomic disparities - African American, Hispanic and South Asian.
40
How can nurses, prevent / limit the spread of COVID?
* wash hands
* avoid touching hands, eyes, nose
* wear a mask
* social distancing
* use alcohol based hand sanitizer
* stay home
41
What is the most common way to determine/rule out if a patient has COVID?
Pharyngeal nasal swab - rapid antigen test.
If positive we can take isolation precautions to isolate the case and prevent spread.
42
Other than the Pharyngeal nasal swab, what are other ways that we can determine if our patient have COVID?
* X-ray - ground-glass opacity in patient lungs (hazy area) - signs of covid
43
What are some non-invasive respiratory support measures that we can provide for Hypoxia?
Cardiorespiratory monitoring - should be continuous for RR and WOB.
Supportive therapy - Suggest self proning (increase life expectancy w/ 13%)
Supplemental oxygen - Maintain over 90%
Alternatives to endotracheal intubation : up oxygen, move from nasal cannula to high flow nasal cannula, bi level non-invasive ventilation, positive airway pressure.
44
When do we need to consider intubating our patients?
If oxygenate or perfusing independently is no longer possible
45
What was the requirement for intubation of COVID patients during the pandemic - who made the decision?
The anesthesiologist.
Criteria : If patient cannot hold a normal sentence without gasping for air, every 3-4 words, then the patient needs to be intubated due to lack of perfusion.
Earlier intubation - higher survival prognosis
46
What is the recommendation for how long we should prone our COVID patients?
12-16 hrs a day as long as their VS are stable (monitor O2 sats)
47
For COVID patients that are intubated, how often do we want to assess the need to intubation?
Daily, we don't want them intubated longer than necessary
48
What will we do for COVID patients that go into septic shock?
Monitor VS and perfusion
Early empiric antimicrobials
Cardiovascular management
49
What can we do for our COVID patients in regards to their GI system?
Initiate early enteral feeding for intubated patients.
Nutrition to fight infection.
50
What do we do for COVID patients who have progressed into renal failure?
* Prepare for hemodialysis
* Continue renal replacement therapy
51
How do we manage the hematologic system in patients w/ severe COVID?
* Prevent venous thrombosis
* Prevent patient from going into DIC
52
True / False
COVID patients are at high risk for clots
True
They are no moving as much as needed and due to the disease process, they are at an increased risk of clots.
Clot can dislodge and cause a pulmonary embolism, stroke or a heart attack.
(important takeaway)
53
Define acute respiratory failure.
The inability of the respiratory system to meet oxygenation, ventilation or metabolic requirements of the patient.
this leads to hypoxemia and hypercapnia.
54
What are the main causes for respiratory failure?
ALL RESULT FROM AN ORIGINAL PROBLEM ( We need to identify cause)
* Impaired function of the CNS
* drug overdose (opioid overdose)
* head trauma
* Infection - viral, pneumonia (very likely )
* hemorrhage
* sleep apnea
* obstruction in airway
These can cause the body to hypoventilation.
55
What are early signs of respiratory failure?
* Restlessness - due to the inability to breathe properly (anxious)
* tachycardia - fight or flight
* HTN
* fatigue
* HA
56
When does rapid deterioration of the respiratory system happen and what are the signs?
The patient's saturations drop to under 90% and we cannot increase saturation with normal nasal cannula.
Hypoxemia will cause them to be ill appearing, they'll be pale. won't talk much.
57
What are late signs of respiratory failure?
This happens when there is a decrease in oxygenation and O2 sats drop below 90%
Early s&s still there, but now body is also trying to compensate ;
* Worsening of SOB
* confusion - less oxygen to brain (esp older pt's)
* lethargy - not oxygenating, perfusing.
* central cyanosis
* diaphoresis - body in fight or flight mode incr sweating
* respiratory arrest - intubation happens here.
58
What are some signs that patient is going into respiratory arrest?
* Decreased breath sounds
* Use of accessory muscles
* Even if the patient is taking deep breaths they are still gasping for air.
* Not able to complete a sentence without gasping for air.
* Once the body can no longer compensate/ is exhausted, the patient will go into respiratory arrest.
59
True / False
Oxygen is considered a medication and we require an order from a doctor to put a patient on oxygen.
True - only exception is emergency situations.
60
What is considered a respiratory emergency ?
Oxygen saturations of less than 60% - we will put them on oxygen and then call the doctor.
61
How do we treat Acute Respiratory Failure?
Identify underlying cause and treat accordingly.
We will notify to the provider if we see s&s in our patients that could lead to respiratory failure e.g. confusion
62
What medication-related factor occurring during hospitalization can lead to respiratory failure?
Too much morphine or other opioid administration.
Or medications w/ o taking into account that the patient has chronic kidney disease and cannot process medication normally and is now OD'ing
63
What orders can we expect to see when a patient is having acute respiratory failure?
* ABG's
* Chest X-ray
* Labs - to rule out infection
* RT to get involved
64
When a patient is on a ventilator we are responsible for :
All of their body systems
- patient can no longer eat, move, breathe on their own,
65
What is positive - pressure ventilation?
Positive-pressure ventilation (PPV) is a method of breathing support in which air is pushed into the lungs under pressure during inspiration, rather than the patient pulling air in on their own.
Patient isn't intubated and this is fitted w/ facemask that cover nose and mouth.
66
What do we need to provide for our patients that are intubated?
Nutritional support - enteral feeding
Important as nutrition aids healing.
67
CPAP can provide oxygen through a mask or can be hooked up to an __________ __________.
Endotracheal tube
68
What does a CPAP provide?
Continuous positive airway pressure (CPAP) - provides pressure to keep alveoli open for better perfusion.
69
What does a BiPAP provide?
Bilevel positive airway pressure
70
What are the indications for noninvasive positive pressure ventilation tools?
* respiratory arrest,
* serious dysrhythmias,
* cognitive impairment,
* head/facial trauma
71
If CPAP and BiPAP, fail and patient is deteriorating, what is the next step?
ET tube intubation.
72
What is the nurses role when patient is to be intubates?
To prepare everything for the intubation.
73
When the alarm on the ventilator goes off, what is the nurses responsibility?
To troubleshoot.
Check if patient is biting on tube, see if the tube is kinked or occluded or unhooked or if its an error in the system.
74
What are things that we are asking ourselves when there is a perfusion problem.
* Is the patient excreting CO2?
* Is it a problem with being able to oxygenate
* Is it both?
These are important questions because we need to ensure that the ventilator setting is meeting the needs of the patient.
75
Once the patient has been intubated what should the nurses assess?
* Symmetry of the chest - both lungs rising. This indicates that the ET tube is in the right place and ventilating properly.
* check breath sounds - air in and out
* check cuff pressure (20-25 mm Hg)
* monitor for aspiration
* suction the patient as needed.
76
How often should we check the cuff pressure of the ET tube?
Q6-8H & change of shift
77
What can happens if the cuff pressure of the ET tube goes down and the tube become loose?
The patient could potentially pull the tube out or the tube could come out on its own which means that the patient is no longer ventilating - could lead to death,
78
What should the ET tube cuff pressure be set at?
between 20-25 mm Hg
79
What should the head of the bed of patients who are intubated be set at?
30 degrees at all times.
This is to prevent aspiration of saliva which may cause pneumonia.
80
What happens if we suction our patient w/ ET tube too much?
It will cause increased saliva production increased risk of ventilator associated pneumonia.
81
How often do we want to reposition intubated patients?
Q2H - to prevent atelectasis, ventilator associated pneumonia and to optimize lung expansion.
82
Intubation for longer than 14-21 days will require :
Removal of the ET tube and have a tracheostomy
83
What are the nursing roles when caring for a patient w/ an ET tube?
Monitoring
Oral care
Positioning
Placement
84
Care of patient w/ an ET tube Immediately After Intubation
(review of chart 19-12) - read for repetition.
Immediately After Intubation
1.Check symmetry of chest expansion.
2.Auscultate breath sounds of anterior and lateral chest bilaterally.
3.Obtain capnography or end-tidal CO2 as indicated.
4.Ensure chest x-ray obtained to verify proper tube placement.
5.Check cuff pressure every 6 to 8 hours.
6.Monitor for signs and symptoms of aspiration.
7.Ensure high humidity; a visible mist should appear in the T-piece or ventilator tubing.
8.Administer oxygen concentration as prescribed by the primary provider.
9.Secure the tube to the patient’s face with tape, and mark the proximal end for position maintenance.
a.Cut proximal end of tube if it is longer than 7.5 cm (3 inches) to prevent kinking.
b.Insert an oral airway or mouth device if orally intubated to prevent the patient from biting and obstructing the tube.
10.Use sterile suction technique and airway care to prevent iatrogenic contamination and infection.
11.Continue to reposition patient every 2 hours and as needed to prevent atelectasis and to optimize lung expansion. 12.Provide oral hygiene and suction the oropharynx whenever necessary.
85
Care of patient w/ an ET tube
Extubation (Removal of Endotracheal Tube)
(review of chart 19-12) - read for repetition.
1.Explain procedure.
2.Have self-inflating bag and mask ready in case ventilatory assistance is required immediately after extubation.
3.Suction the tracheobronchial tree and oropharynx, remove tape, and then deflate the cuff.
4.Give 100% oxygen for a few breaths, then insert a new, sterile suction catheter inside tube.
5.Have the patient inhale. At peak inspiration, remove the tube, suctioning the airway through the tube as it is pulled out.
86
Care of patient w/ an ET tube
Care of Patient Following Extubation
(review of chart 19-12) - read for repetition.
1.Give heated humidity and oxygen by facemask and maintain the patient in a sitting or high-Fowler position.
2.Monitor respiratory rate and quality of chest excursions. Note stridor, color change, and change in mental alertness or behavior.
3.Monitor the patient’s oxygen level using a pulse oximeter.
4.Keep patient NPO (nothing by mouth), or give only ice chips for next few hours.
5.Provide mouth care.
6.Educate the patient about how to perform coughing and deep-breathing exercises.
87
Indications for Mechanical Ventilation Laboratory Values :
PaO2 <55 mm Hg
PaCO2 >50 mm Hg
pH <7.32
88
Indications for Mechanical Ventilation based on clinical manifestations :
* Apnea or bradypnea
* Respiratory distress with confusion Increased work of breathing not relieved by other interventions
* Confusion with need for airway protection
* Circulatory shock
* Myasthenia Gravis
* Guillain Barre
* DIC
* Controlled hyperventilation (e.g., patient with a severe head injury)
89
What is the "continuous mandatory ventilation (CMV) " setting on the ventilator ?
100 % support
This setting delivers a preset tidal volume or pressure and a rate of respirations. Every breath that the patient takes is preset by the machine. This provides full ventilator support.
Rate, dept, and amount of inhalations and expirations.
90
What is the "intermittent mandatory ventilation" (IMV) setting on the ventilator ?
* Mix of spontaneous breaths and mechanically assisted ventilation.
* RR is set at a preset interval w/ preset volume, however the patient is able to increase RR by initiating their own breaths,
Benefit is that patients are using their own muscles when they initiate their own breaths.
91
What is the benefit of the IMV setting on the ventilator?
Helps the patient when they are initiating their own breath, as well as using their own muscles which prevents muscular atrophy.
It also helps monitor O2 intake and CO2 output.
92
What is the "Synchronized Mandatory Ventilation" (SIMV) setting on the ventilator ?
* Preset TV and number or breaths, but the patient can also initiate breaths without help from the ventilator.
* Ventilator can sense when patient is about to initiate a breath , and the more adequate breaths the patient takes the less the ventilator is used.
* commonly used in weaning patients
93
What is the "Positive End-Expiratory Pressure " (PEEP) setting on the ventilator ?
* This setting helps keep the alveoli open to ensure CO2 excretion.
94
When do we not need to use the PEEP setting on the ventilator?
When there is no CO2 issue.
95
What can happen if the PEEP setting is too high ?
Overexpansion of the lung which may cause barotrauma - alveolar rupture and pneumothorax.
96
What needs to happen for a patient to be able to be weaned of the ventilator?
* Hemodynamically stable enough
* Adequate spontaneous breaths on the lowest setting of the ventilator.
* VS and ABG's
* Patients should be slowly woken up
* We need to keep in mind that they may be scared.
97
Which Ventilator setting is normally used when weaning patients off the ventilator?
SIMV "Synchronized Mandatory Ventilation"
98
What are our responsibilities as nurses to assess right before we take out the ET tube.
* Look for signs of exhaustion
* look for signs of hypoxia and correlate this with ABG's
* Before we take the tube out we want to ensure that they are functioning on room air, because if they're not, then we will turn the ventilator back on.
* We do not remove the tube until we know that they are hemodynamically stable.
99
Ventilator Problems
If an increase in peak airway pressure is caused by Coughing or plugged airway tube, what is the solution to this?
Suction airway for secretions and empty condensation fluid from circuit.
100
Ventilator Problems
If an increase in peak airway pressure is caused by Patient-ventilator dyssynchrony - what is the solution to this?
Adjust sensitivity and consider administering sedatives as prescribed
101
Ventilator Problems
If an increase in peak airway pressure is caused by Decreasing lung compliance - what is the solution to this?
Manually ventilate patient.
Assess for hypoxia or bronchospasm.
Check arterial blood gas values.
Sedate only if necessary.
102
Ventilator Problems
If an increase in peak airway pressure is caused by Pneumothorax - what is the solution to this?
Manually ventilate patient; notify primary provider.
103
Ventilator Problems
If an increase in peak airway pressure is caused by Atelectasis or bronchospasm - what is the solution to this?
Clear secretions.
104
Ventilator Problems
Decrease in pressure or loss of volume is caused by Leak in ventilator or tubing or cuff on tube/humidifier not tight - what is the solution to this?
Check entire ventilator circuit for patency.
Correct leak
105
If a patient on a ventilator is experiencing cardiovascular compromise caused by decrease in venous return due to application of positive pressure to lungs - how do we resolve this?
* Assess for adequate volume status by measuring heart rate, blood pressure, central venous pressure, pulmonary capillary wedge pressure, and urine output.
* notify primary provider if values are abnormal.
106
If a patient on a ventilator is experiencing a Barotrauma/pneumothorax caused by application of positive pressure to lungs or high mean airway pressures lead to alveolar rupture - how do we resolve this?
Notify primary provider.
Prepare patient for chest tube insertion.
Avoid high pressure settings for patients with COPD, ARDS, or history of pneumothorax.
107
If a patient on a ventilator is experiencing a pulmonary infection caused by
the bypass of normal defense mechanisms, frequent breaks in ventilator circuit, decreased mobility or impaired cough reflex - how do we resolve this?
Use strict aseptic technique.
Provide frequent mouth care.
Optimize nutritional status.
108
What assessments should we be doing on our patients who are receiving mechanical ventilation?
* Systematic assessment of all body systems
* In depth resp assessment incl all indicators of oxygenation status.
* Neuro status
* Effective coping and emotional needs
* Comfort level and ability to communicate needs
* Assessment of equipment and settings
109
What can happen if the ET tube becomes dislodged?
* Laryngeal swelling
* Hypoxia
* Bradycardia
* Death
110
If the ET tube does come out or is dislodged what should we immediately do?
Bag mask ventilate , then call for help
111
What does "Increase in Peak airway pressure" mean?
An increase in Peak Airway Pressure (PAP) means more pressure is required to deliver a breath into the lungs, usually because there is increased resistance or decreased lung compliance.
112
The alarm goes of because there is an increase in Peak Airway Pressure - what is the common cause of this? what do we do?
Patient coughing or biting on the tube - bite block & provide education as to why they should not be biting the tube.
Increase sedation, check tubing (tubing may be kinked and the increase is not caused by the patient)
113
What does a decrease in ventilator pressure mean?
A decrease in ventilator pressure (low airway pressure alarm) means the ventilator is meeting less resistance than expected—most often because air is leaking out or not reaching the lungs.
114
The alarm goes of because there is an decrease in pressure or loss of volume - what is the common cause of this? what do we do?
May be caused by increase in compliance or leak in the ventilator, cuff or tubing.
Check the entire ventilator and its circuit for patency and correct the leak.
115
What happens when our patient on ventilator has a barotrauma or pneumothorax, what may this be caused by? What do we do?
* Too much positive pressure in the lungs which leads to alveoli rupture.
Notify the provider straight away.
116
What are some ways that we can attempt to prevent a pneumothorax or barotrauma?
We need to know our patients medical hx well and know which patients are at an increased risk for this, so that we can closely monitor them.
117
Which patients are at an increased risk for pneumothorax or barotrauma?
Patients w/ COPD, ARDS, or hx of pneumothorax.
118
If a patient does develop a pneumothorax or barotrauma, what do we need to prepare for?
A chest tube insertion to treat this.
119
What is crucial to prevent ventilator associated pneumonia?
HOB elevated to 30 degrees at all times
Frequent oral care
120
For patients waking up after being ventilated and are delirious, what interventions do we do?
* Non-pharmacological methods to treat
* Reorient pt to time and location and why they are here.
* offer family support
* Early exercise & ambulation
121
What are the treatment goals for our patients who are on mechanical ventilator?
* Ensure cuff is always inflated ( q6-8h) - chart so everyone knows the pressure.
* Maintenance of patent airway
* Optimal gas exchange
* Absence of trauma or infection (cleaning hubs, oral care, clean hands, sterile technique)
* Attainment of optimal mobility - delegate ROM to patient family.
* Adjustment to nonverbal methods of communication - can pt shake heads yes or no etc, squeeze hands.
* Successful coping measures
122
What are the nursing interventions for our patients that are on mechanical ventilator?
Enhancing gas exchange
Promoting effective airway clearance
Preventing injury and infection
Promoting optimal level of mobility
Promoting optimal communication
Promoting coping ability
123
How can we reduce pain in our patients who are intubated w/o depressing their respiratory drive?
* non-opioid analgesics i.e Tylenol
* nonpharmacologic methods such as repositioning
124
How do we monitor our intubated patients for adequate fluid balance?
* Assess peripheral edema - give furosemide if VS are stable, kidney labs are stable.
* I&O & daily weights
125
How do we promote effective airway clearance in patients that are intubated?
* Assess lung sounds at least q2h
* Measures to clear airway: suctioning, position changes, promote increased mobility
* Humidification of airway
* Administer medications
Suctioning only if excessive secretions! Can increase saliva production.
126
How do we prevent injury and infection in patients who are intubated?
* Infection control measures
* Tube care
* Cuff management
* Oral care
* Elevation of HOB
127
What is one of the biggest complications that we see in patients on ventilators?
Ventilator-Associated Pneumonia (VAP) (occur in 27% of all vented patients) - this is the only pneumonia that nurses are responsible for.
128
What does Ventilator-Associated Pneumonia decrease?
Lung functionality.
129
What is the VAP bundle?
Current best practices can include the implementation of specific evidence-based bundle interventions that, when used together (i.e., as a “bundle”), improve patient outcomes to prevent VAP.
130
What are the 5 elements of the VAP bundle?
*Elevation of the head of the bed (30° to 45°)
*Daily “sedation vacations” and assessment of readiness to extubate
*Peptic ulcer disease prophylaxis
*Deep venous thrombosis (DVT) prophylaxis
*Daily oral care with chlorhexidine (0.12% oral rinses)
131
What is meant by daily “sedation vacations,” and how does this tie into assessing readiness to extubate?
* Protocols should be developed so that sedative doses are purposely decreased at a time of the day when it is possible to assess the patient’s neurologic readiness for extubation.
*Vigilance must be employed during the time that sedative doses are lower to ensure that the patient does not self-extubate.
132
What effect does DVT prophylaxis have on preventing VAP?
The exact relationship is unclear. However, when appropriate, evidence-based methods to ensure DVT prophylaxis are applied, then the rates of VAP also drop.
133
Is the following statement true or false?
Alarm fatigue occurs when nurses become desensitized to alarms and do not respond with sufficient speed.
True
Rationale: Alarm fatigue occurs in ICU settings and can be life threatening for those patients receiving mechanical ventilation. To prevent alarm fatigue, consider the layout of the critical care unit, devise protocols for setting of alarms based on best practices, and educate staff on how to set and respond to alarms.
134
What is Acute Respiratory Distress Syndrome (ARDS) ?
A complex clinical syndrome rather than a single disease - carries a high risk of mortality.
135
What causes ARDS?
* Direct or indirect pulmonary injury in a previously healthy individual.
These can be severe aspirations (drowning),
infectious pneumonias,
toxic inhalations,
lung contusions w/ trauma,
severe pulmonary edema,
sepsis,
systemic inflammatory response syndrome, burns, trauma, blood transfusion reactions.
136
Mortality rate in ARDS is ______ - ________ %
27-50%
137
What is ARDS characterized by?
sudden, progressive pulmonary edema, increasing bilateral lung infiltrates visible on chest x-ray, and absence of an elevated left atrial pressure
138
What is the Patho behind ARDS?
Inflammation triggers the release of cellular and chemical mediators that causes injury to the alveolar capillary membrane and causes structural damage to the lungs - these areas of the lung becomes non-function and cannot ventilate.
The blood is shunted to remaining areas of lung for perfusion.
139
True / False
Patients w/ ARDS require a high volume of supplemental oxygen therapy?
False - patients with ARDS do not respond to supplemental oxygenation.
140
How do these patients normally present to the ED?
* Present w/ severe dyspnea
* ARDS occur within 72 hrs of an initial insult to the lungs.
141
How do ARDS present itself clinically?
* Resemble severe pulmonary edema (crackles and intercostal retractions & BNP lvls)
* Severe Hypoxemia
142
What frequent assessment is essential for ARDS patients?
Frequent respiratory assessments due to the severe ARDS
143
What is key to identify in order to treat ARDS?
Underlying cause.
144
What can we do to increase our patients chance of survival when they have ARDS?
Supportive care to compensate for the severe respiratory function
Almost always ET tube intubation & ventilation.
145
Which ventilator setting is critical in ARDS patients?
PEEP - because the alveoli will be forced open and this will help with diffusion of O2 and CO2
(MUST REMEMBER FOR EXAM)
146
What abnormal VS is common in ARDS patients?
Systemic hypotension as a result of hypovolemia, which is secondary to leakage of fluid into the interstitial space and depressed cardiac output from the high lvls of PEEP.
147
What medical agents may be required for our ARDS patients?
Vasopressors or inotropic agents.
148
What positioning have been shown to increase oxygenation & survival rate in ARDS patients?
Prone positioning - monitor for decompensation w/ position changes (higher risk than w/ COVID)
149
Why is it imperative that we reduce the anxiety lvl experienced by ARDS patients?
We need to limit oxygen consumption and needs.
Anxious patients will breathe quicker, have a higher HR and BP which requires increased amounts of oxygen.
150
Where does DVT's usually originate from?
* Large deep veins
* lower extremity
* Right side of heart w/ untreated A-fib
* Veins in pelvic region of the body
151
what causes a DVT?
Pooling of blood in certain areas, often caused by immobility
152
What happens to a DVT once it breaks off?
It may travel to the pulmonary tree and get stuck, this will cause an pulmonary embolism which is a medical emergency and will quickly lead to death if untreated.
153
Define a Pulmonary embolism.
Obstruction of the pulmonary artery or one of its branches by a thrombus (or thrombi) that originates somewhere in the venous system or in the right side of the heart.
154
How does the inflammatory process r/t a the thrombus in the lungs manifest itself?
Inflammatory process obstructs area, results in diminished or absent blood flow
Bronchioles constrict, further increasing pulmonary vascular resistance, pulmonary arterial pressure, and right ventricular workload
Ventilation–perfusion imbalance, right ventricular failure, shock occurs
155
Why is PE difficult to treat?
Because it has a non-clinical presentation, less than 10% of patients with a fatal PE receives adequate treatment.
156
The degree of symptoms in PE depend on :
Where the embolus lands in the lungs.
157
True/ False
Often the discovery of a PE is incidental and due to the patient being worked up for other symptoms.
True
158
PE should be expected in :
* Any pt w/ new onset dyspnea , tachycardia, sustained hypotension, chest pain, and cough w/ or w/o hemoptysis (blood)
* Not all symptoms needs to be present.
159
Which patients are at the highest risk of developing DVT's?
* Post-surgical patients
* Patients w/ cardiac arrhythmias such as A-fib
* Trauma
* Pregnancy
* Heart failure
* Hypercoagulability
* Immobility, venous stasis
* vascular endothelium damage
160
What is the most common symptom of PE?
Dyspnea - pain w/ breathing
Alert should go off if this happens in post surgery patients.
161
What are the factors of the Virchow’s triad that describes the three major factors that increase the risk of developing a pulmonary embolism ?
Venous stasis - Slow or stagnant blood flow
Endothelial injury - Damage to the blood vessel lining
Hypercoagulability - Increased tendency for blood to clot
162
Knowing the Virchow’s triad , what are specific risk factors for PE?
* Pregnancy
* Trauma
* Surgery
* Heart failure
* Immobility
163
What is the best way to prevent a PE?
* Early ambulation (best way to prevent venous stasis )
* Anti-embolism stockings & SCD's
164
What are the treatments of PE?
* Measures to improve respiratory and vascular status
* Anticoagulation and thrombolytic therapy
* Surgical interventions
165
Which drug is the most common medication to treat a PE?
Heparin - length of treatment depend on pt age, comorbidities present and risk for reoccurrences.
166
When is IV heparin indicated in patients with an PE?
*Indicated for unstable patients where low molecular weight heparin cannot be used.
* these are patients w/ sudden onset of chest pain and difficulty breathing.
167
What is extremely important to make sure when our patients are on Heparin?
That they are not bleeding out.
168
If our patient has had a recent bleeding episode or cannot take systemic anticoagulants, what treatment can we do instead?
We can place a IVC filter in the inferior vena cava to strain the cloths and prevent them from circulating through the system.
169
What lifestyle changes can patients do to prevent PE's ?
Weight loss
Smoking cessation
Regular exercise
170
What types of chest traumas are there?
Blunt trauma
Penetrating trauma
Pneumothorax
171
What are types of blunt chest trauma?
Responsible for 20-25% of all trauma deaths.
Sternal, rib fractures
Flail chest
Pulmonary contusion
172
What are the most common causes of blunt chest trauma?
MVH's, Airbags, steering wheel, seatbelt, bicycle crashes with handlebars.
173
Hypoxemia from the blunt trauma occur due to :
Disruption of the airway due to the injury of the rib cages, respiratory muscles, collapsed lung or pneumothorax.
174
What is the primary assessment when there has been blunt trauma?
* Symmetry of chest wall
* movements
* breath sounds
* open chest wounds
* impaled objects
* ensure no tracheal deviation
* cyanosis
* crepitus
* nasal flaring
* VS
175
How do we manage patients w/ blunt chest trauma?
* Aggressive resuscitation
* Immediately establish a patent airway w/ oxygen support
* intubation if necessary
176
What causes a Flail chest?
Caused by a free floating segment of patient rib cage from multiple rib fractures.
177
How do we assess a Flail chest?
Assessment is paradoxical movement on inspiration - rib cage is sucked inward toward the mediastinum, and the mediastinum will shift to the affected side.
On expiration the flail segment will bulge and move back towards the affected side again.
178
Patient w/ penetrating trauma is often in ___________.
shock
179
What are patients w/ penetrating trauma at high risk for?
Massive blood loss.
180
What are s&s of decreased oxygen delivery to the brain caused by blood loss?
* Agitation
* Irrational behavior
* Combative behavior
Associated w/ high risk of death.
181
With penetrating trauma, is it ok to remove the object in the patients chest?
No - also ensure the patient is not removing the object.
Pulling the object out may cause the patient to bleed out.
182
When does a Pneumothorax occur?
When the parietal or the visceral pleura is breached and the pleural space is exposed to positive atmospheric pressure - the air that comes in causes the lung to collapse.
183
When does a simple pneumothorax most commonly occur?
When air enters the pleural space through a rupture of a bleb or a bronchopleural fistula.
184
When does a spontaneous pneumothorax happen?
In a healthy person in absence of trauma, when a bleb or blister ruptures on the surface of the lung and allows air to come into the pleural cavity.
185
True / False
A traumatic pneumothorax is a medical emergency.
True
186
What do you want to do as soon as possible in a traumatic pneumothorax?
Stop the flow of air that is coming into the pleural cavity through the opening of the chest.
This is a lifesaving procedure.
187
What is sucking chest wound?
A sucking chest wound is an open pneumothorax — a life-threatening chest injury where air is sucked into the chest cavity through an open wound during inspiration.
Occluding wound is priority nursing action!!
188
What is a tension Pneumothorax?
Opposite of an open pneumothorax.
Complications of other pneumothoraxes. Air is pulled into the pleural space from a lacerated lung or small opening - with each inspiration the air gets trapped repeatedly until pressure builds up to the point where the air collapses and the heart and the vessels in the traches will shift to the unaffected side.
- Mediastinal shift
189
What is the first indicator of a tension pneumothorax?
Sudden pain and use of accessory muscles.
190
What is the first job the nurse will have once a tension pneumothorax has been establishes.
Prepare the patient for a chest tube insertion after establishing a patent airway.
191
What is the treatment goal for tension pneumothorax?
Evacuate the air or blood from the pleural space and allow the lungs to re-inflate.
192
Chest tubes are put in place as a ______ ________ ________.
Closed draining system.
193
What are chest tubes used for?
Re-expand lungs
Remove air, fluid and blood from the pleural space / body.
194
What happens if the chest tube becomes disconnected?
Air can enter the pleural space and cause a pneumothorax
195
If a chest tube becomes disconnected and causes a pneumothorax, what is the immediate action to save the patients life?
Submerge the open end that came disconnected into a bottle of water (sterile water) to close the system. This will prevent air from going into the chest tube and maintain the closed system.
196
Where should the chest tube draining system be put in place?
Always kept below the patient's heart when suctioning is not on. This is for gravity purposes the thoracic pressure is equal to a water seal.
We would do this when we disconnect the patient from suctioning, have tests done, walk the halls.
