Transcript Advanced Nursing Concepts Part 2

Advanced
Nursing
Concepts Part 2
Ventilatory Assistance
Sandra H. Lewis, ARNP-BC-ADM
Review of Anatomy and
Physiology
• Respiratory system is divided into:
• The Upper Airway=nasal cavity, the
pharynx…it conducts, warms humidifies
and filters.
• The Lower Airway= the larynx, trachea,
and right and left main stem bronchi ( the
bifurcation at the angle of Louis is at the
level of the 5th thoracic vertebra and is
called the carina)
Cont..
The right bronchus is wider, straighter and shorter
(making it easier to accidentally intubate)
The lungs consist of two lobes on the left and three
lobes on the right. Each lobe is further divided
into lobules that are supplied by one bronchiole.
The lungs are covered by the pleura. The visceral
pleura covers the lung surfaces and the parietal
pleura covers the internal surface of the thoracic
cavity. Between the pleura there is a thin fluid
layer that allows the sliding action as respiration
occurs.
Human Respiration
Respiratory System.url
Regulation of Breathing
• The rate, depth and rhythm of ventilation
are controlled by The respiratory centers
in the medulla and the pons.
• When CO2 is HIGH or the O2 level is LOW,
chemoreceptors in the respiratory center,
the carotid arteries, and the aorta send
messages to the medulla to stimulate
respiration.
• Persons with NORMAL lung function are
stimulated by HIGH levels of CO2
Continued..
• In persons with COPD, the stimulus
to breathe is the LOWER level of
O2….higher levels of CO2 are
baseline…
• So what do you think is a major
nursing consideration about O2
therapy for persons with COPD?
WOB (Work of Breathing)
• Compliance= The measure of
stretchability of the lung and chest wall…
is primarily determined by the elastic
recoil that must be overcome before lung
inflation can occur.
• EXAMPLES OF GREATER ELASTIC RECOIL:
ARDS, pulmonary fibrosis, pulmonary
edema…lungs are stiffer and difficult to
distend Compliance is LOW…greater
pressures are required to expand lungs.
WOB cont..
• ARDS, X-RAY
• In emphysema, destruction of lung
tissue and enlarged air spaces cause
the lungs to lose their elasticity.
• The decrease in elastic recoil causes
compliance to be high.
• Therefore lower pressures are need
to expand the lungs.
Cont…
• Emphysema…Notice the flattening of
diaphragms, Increased lung
volumes, Diffuse hyperlucency
Resistance
• The opposition to gas flow in the
airways.
• Examples: mucous, edema,
bronchospasm
• Remember…the smaller the internal
diameter of artificial airway increases
resistance to air flow..
Spirometer
• Used to measure lung volumes.
• Allows the practitioner to assess
baseline pulmonary function and to
monitor changes.
Lung volumes
• Volumes and capacities are usually
stated for “healthy men”
• Volumes for women are 20-25% less
• Volumes decline with age.
• Tidal Volume= Volume of normal
breath
Health History
• Tobacco use, type, amount, #years used…pack
years=packs cig a day x years smoked
• Occupational…asbestos, coal mining, farming
• Sputum
• SOB, CP, dyspnea, cough, anorexia, weight loss
• Respiratory med hx: inhaled, steroids,
bronchodilators
• OTC Drugs
• Allergies
• Last CXR and TB screening
Physiological Changes with
Age
• Decreased alveolar surface
• Decreased alveolar elasticity
• Decreased chest wall distensibility
• Decreased physiological
compensatory mechanisms: (resp,
cardiac, renal, immune)
Physical Exam
Respiratory Assessment
• INSPECTION
–
–
–
–
–
landmarks; scapula , vertebrae
Respiratory rate
Position and use of accessory muscles
Colour
Breath sounds
PERCUSSION
• Posteriorly
– upper and lower lobes
• Start with apical areas, moving L to R
and then slowly moving down to 10 ICS.
• Resonance - long, low pitch sound, heard
over most lung fields
• Hyperresonance - low sounds (abnormal)
heard when emphysema
• Flatness/dullness - pneumonia and
atelectasis.
PALPATION
– breathing excursion
• position palms of hands on patients back
between 8th and 10th ribs. Thumbs are
‘free floating’. Ask patient to take a
breath. Each hand should move the same
distance (3-5 cms)
– tactile Fremitus
• Using the ball of your hand , place them
on the posterior wall of the chest,
starting in the apical lobe area, ask your
patient to say ‘99’. You should feel
vibrations. In pneumonia, there is
increased intensity of the vibrations and
with pneumothorax, reduced intensity.
AUSCULTATION
• Follow same pattern as used when
percussing.
• Observe for expected breath
sounds in the region assessing
– Bronchial
– Bronchovesicular
– vesicular
• Listen for Crackles & Wheezes
• Pleural rub
DOCUMENTATION
• Respiration rate, skin colour, physical
position and respiration sounds INSPECTION
• Tactile fremitus, and respiratory
excursion - PALPATION
• Breath sounds, describe and compare
from lung apex to base as well as from
LR
• Presence of crackles and/or wheezes;
state their location - AUSCULTATION
Signs and Symptoms of
Hypoxemia
• Integument: Pallor, cool, dry, diaphoresis,
cyanosis
• Respiratory: Dyspnea, tachypnea,
accessory muscle use
• Cardiovascular: Tachycardia,
dysrhythmias, CP, HTN with increased
heart rate, hypotension with decreased
heart rate.
• CNS: Anxiety, restlessness,
combativeness, fatigue, confusion, coma
Common Acid-Base
Abnormalities
• See Box 8-2 page 172
• Resp. Acidosis (CO2 retention):
COPD,CNS Depression, restrictive
lung disease
• Resp. Alkalosis (hyperventilation):
Anxiety, pain, stimulants, pneumonia
CHF, pulmonary edema
Cont..
• Metabolic Acidosis (increased acids): Renal
failure, DKA, Lactic acidosis, drug OD…
Methanol, salicilates, ethylene glycol (loss
of base)..diarrhea
• Metabolic Alkalosis ( gain of base): excess
antacids, or sodium bicarb…. or (loss of
acids), vomiting, NG suction, Low K+ or
CL, diuretics, increased aldosterone level
ABG’s
• Blood Gas Analysis Handout
• Pages172-173.Critical Care Nursing
Pulse Oximetry
• Measures SpO2, reflects: SaO2 (arterial
saturation)
• A light emitting diode measures pulsatile
flow and light absorption of the
hemoglobin.
• Accurate readings require a warm, well
perfused area.
• Patient motion and edema at the site
adversely effect results…nail polish,
sunlight and florescent light also interfere
Oxygen Administration
IF YOUR PATIENT IS
BLUE….
...TRY SOME
O2
HeadTilt/ChinLiftProcedure
• Tongue, the most
common cause of
airway
obstruction
• One hand on
patient’s
forehead, fingers
of opposite hand
under bony part
of the chin
• Lift the chin
forward and
support the jaw,
Modified Jaw Thrust
• Used when
possibility of Cspine injury exists
• Grasp the angles
of the patient’s
lower jaw and lift
with both hands,
displacing the
mandible forward
• If the lips close,
retreat the lower
lip with thumb
Oral Airways
• are designed to
keep the tongue
from falling back
and blocking the
upper airway
• easily available in
six to nine sizes
• are only used in
unresponsive
patients without a
gag reflex
• do not eliminate
the need to
Oral Airway Sizing
• To choose the
proper size, hold
the airway against
the side of the
patient’s face. It
should extend from
the corner of the
patient’s mouth to
the angle of the
jaw.
Oral Airway Insertion
• Open mouth with cross
finger technique. Insert
airway with tip pointing
up to avoid pushing
tongue backward.
• Rotate airway tip slowly
downward until its
curve matches the
curve of the tongue.
• The flange of the
airway should rest
against the patient’s
lips.
Nasopharyngeal Airways
• Curved, flexible rubber or plastic
tubes inserted into the patient’s
nostril
• Use on responsive patients who need
an airway assist
Nasopharyngeal Airway
Sizing
• Measure length
from tip of
patient’s nose to
earlobe
• Diameter of airway
should fit patient’s
nostril without
excessive tightness
Oxygen Tanks and
Regulators
• Always green-designates O2
• Various tank sizes
– D, E, M
• Yoke vs. Threaded outlet
• Tank pressure-2000 lbs. per sq. in.
• Common regulators
– fixed orifice, bourdon gauge
Delivery Devices
• Nasal cannula
– Flow rate 2-6 lpm
• Non-Rebreather mask
– Flow rate 10-15 lpm
• Two rescuer Bag Valve Mask (BVM)
– Flow rate 15 lpm
Set up of Tank/Regulator
• Step 1-open tank to blow out dust
• Step 2-Attach regulator (o-ring)
• Step 3-Open tank, check pressure
• Step 4-Attach proper delivery device
• Step 5-Open flow to proper lpm for
device
• Step 6-Place delivery device on
patient
Break down of
Tank/Regulator
• Step 1-Turn off flow
• Step 2-Remove mask/cannula , turn
off tank
• Step 3-Open flow meter to
relieve/bleed pressure-close when
complete
• Step 4-Remove regulator
Safety Considerations
• Position/placement of tank
• Properly fitting regulator
• Close all valves when not in use
• O2 fuels fire-not a flammable gas
• Do not roll tanks on side or bottom
• Inspect valve seats and o-rings
• Store tanks in cool, well ventilated
area
• Have tanks tested on regular basis
Oral Vs Nasotracheal
Intubation
• Box 8-6 on page 181 in Critical Care
Nursing
Look carefully at advantages and
disadvantages.
Equipment for Intubation
• See Figure 8-19 page 182
• Be able to set up for an intubation
and discuss choosing ET size and
rationale for nasal or tracheal
intubation.
ET & More info
• How quickly should the ET be placed? 30 seconds
• Where should the tip end? 3-4 cm above the carina
• What is the role of rapid sequence intubation? Emergency airway
management, while decreasing the risk of aspiration,
combativeness and injury to the patient.
• HOW is RSI achieved? Neuromuscular blocking agent
(Succinylcholine) + potent sedative (fentanyl or other).
• What is Sellecks maneuver? Pressure on the cricoid is applied.
• Why is it used? To decrease risk of vomiting and therefore
aspiration
• When can blind intubation be done? Only if the patient is capable
of spontaneous respirations.
• How long can a ET tube generally be left in place? 3-4 weeks.
• Where is the incision made for a tracheostomy? At the level of
the cricoid or between the 1st and second tracheal ring.
Suctioning the Intubated
Patient
• See box 8-9 page 188 Critical Care
Nursing
• Discuss proper suctioning technique
Negative Pressure
Ventilation
• Used for sleep apnea, neuromuscular
problems and when Chronic
Respiratory Failure patients need
short periods of ventilation.
• See figure 8-24
• Examples: iron lung, tank ventilator
Noninvasive positive
pressure ventilation
• See figure 8-25 page 189 Critical
Care Nursing
• Face Mask covers mouth and nose.
• Used in those requiring ventalatory
support post intubation to resolve
hypercapnia and short
term…pulmonary edema, or for
patient who refuses intubation
Controlled Ventilation
• Rarely used because of the
superiority of Assist/Control (causes
less anxiety, less hemodynamic
instability).
• Locks out patients attempts at
respiration
• Indicated for high c-spine injuries,
patients with NO respiratory effort,
chemically paralyzed patients
Assist Control
• Helps preserve muscle tone, reduces
dyssynchrony (fighting the vent)
• Potential complication of A/C=resp
alkalosis (patients own resp rate too
high triggering the vent…this can be
adjusted by adjusting the sensitivity,
sedating the patient if needed, or
using IMV)
SIMV
Synchronized Intermittent
Mandatory Ventilation
• Delivers a preset Vt at a preset rate and
allows the patients own breaths at his own
rate and depth between the ventilator
breaths.
• Guarantees at set number of breaths
• Helps prevent muscle weakness and
hyperventilation.
• Can increase muscle fatigue associated
with patient efforts
PEEP
Positive End Expiratory
Pressure
• Higher that atmospheric pressure at the
end of expiration
• Increases oxygenation by preventing the
collapse of small airways and maximizing
the number of alveoli available for gas
exchange.
• Often ordered to reduce the FiO2 needed
for optimal oxygenation
PEEP cont…
• “physiologic peep” = 3-5 cm H2O
• Usual peep range 3-20 cm H2O
• Can decrease cardiac output (secondary to
decreased venous return.)
• Increases risk of volutrauma
• Increased ICP from decreased venous
return to the head
• Can cause alterations in renal function
secondary to reduced renal blood flow.
CPAP
Continuous Positive Airway
Pressure
• The concept of peep is used to
augment the patients residual
functional capacity and oxygenation
during spontaneous breathing
• Administered through nasal of face
mask or through artificial airway
• Often used in obstructive sleep
apnea
Some Ventilator
Terminology
• Tidal Volume- amount of air delivered with
each preset breath, usually 10-15 ml/kg,
however, recent research indicates lower
Vt=less volutrauma…this could not be
used in head injured patients because of
the resultant hypercapnia…increases
intercranial pressure because of
vasodilation from CO2
Cont.
• Respiratory Rate- Frequency of
breaths delivered
• FiO2- The percentage of inspired
oxygen 21-100%, after emergency
intubation 50-100%...adjustments
made based on ABG’s
• Sigh-A mechanically set breath with
greater Vt. (volume), used to
prevent atelectasis.
Complications of Mechanical
Ventilation
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Volutrauma
Intubation of Right main stem bronchus
ET out of place or unplanned extubation
Tracheal Damage
Oral or Nasal mucosa damage
Problems associated with O2 administration
Resp Acidosis or Alkalosis
Aspiration
Infection
Inability to wean
Communication
Care of the Patient with
Mechanical Ventilation
• Medications
• Nutritional Support
Trouble shooting the Vent
• Never Shut off alarms
• Manually ventilate the patient if you cannot
trouble shoot the problem or suspect mechanical
failure.
• Volume alarms-low=patient not receiving preset
Vt.
• Pressure Alarms-High= pressure exceeding
preset limit, Look at patient factors..coughing ,
biting tube, excess secretions, pulmonary
edema,bronchospasm, pneumo or
hemothorax….also kinks in the ventilator tubing
Cont…
• Apnea Alarms- Ventilator does not
detect spontaneous respiration within
the preset interval…especially
important when patient has low set
rate.