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33 Cards in this Set
- Front
- Back
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Acute Respiratory Failure
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PO2 less than 60, 02 less than 90%, PA CO2 greater than 50
Mechanical Ventilation |
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Ventilatory Failure (Causes)
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Extrapulmonary
Neuromuscular disorder Spinal cord injury CNS dysfunction Chemical depression Keyphoscoliosis Morbid obesity Sleep apnea Obstruction/constriction Intrapulmonary Airway disease V/Q mismatch |
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Problems With Oxygenation
Common Causes |
Low atmospheric oxygen concentration
Pneumonia CHF Pulmonary embolism ARDS Abnormal HGB Hypovolemic shock Hypoventilation |
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Ventilation/Oxygenation Mismatch
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Hypoventilation
Pulmonary Embolism Hypoxia RT perfusion problem Tachypnea Keeps pCO2 normal or low But pO2 continues to decrease |
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Assessment of ARF
Signs and symptoms of |
Hypoxemia (PaO2 < 60 mm Hg)
Hypercapnia (PaCO2 > 50 mm Hg) Oxygen Saturation < 90% |
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s/s
Hypoxemia |
Dyspnea, tachypnea
Orthopnea Cyanosis Restlessness Apprehension Confusion Tachycardia Dysrhythmias HTN Metabolic acidosis Interventions Support ventilation PO2 and PCO2 O2 therapy Positioning anxiety Energy conservation Medications |
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s/s
Hypercapnia |
Dyspnea
Headache Papilledema Tachycardia HTN Drowsiness, coma Systemic vasodilation Heart failure Respiratory acidosis Interventions Support ventilation PO2 and PCO2 O2 therapy Positioning anxiety Energy conservation Medications |
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Indications for Intubation
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Airway protection
Provide positive pressure or high oxygen concentration Bypass airway obstruction Facilitate pulmonary hygiene |
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Endotracheal Intubation
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Short term (10-14 days)
Maintain patent airway work of breathing Remove secretions Provide ventilation & O2 |
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Preparation for Intubation
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Emergent situation
Explain procedure May require sedation Attempts no longer than 30 seconds Stabilize endotracheal tube Verify placement |
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Immediate Care after intubation
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Assess tube placement
Breath sounds CXR (2-3 cm ↑ carina, radio-opague marking) End tidal CO2 Symmetrical rise and fall of the chest Prevent dislodgement Securing with tape (note cm marking) Sedation Restraints (last resort) Oral/ ET tube suctioning Communication |
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Mechanical Ventilation Indications
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Temporary life support
Life long Progressive neuromuscular diseases Hypoxemia & progressive alveolar hypoventilation Respiratory Acidosis Respiratory support after surgery |
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Types of Ventilators
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Negative Pressure
Iron Lung Positive Pressure (Push air into lungs) Air delivered until preset pressure reached Time cycled (Pediatrics/Neonates) Push air in with preset time Volume cycled Push air in until preset volume reached |
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Assist-Control Ventilation
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More commonly used
Tidal volume & rate preset If client does not trigger breath, ventilator will deliver breath Advantage- client controls rate of breathing Disadvantage - respiratory rate hyperventilation respiratory alkalosis |
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SIMV
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Similar to A/C ventilation
Spontaneous breathing between ventilator breaths at clients own rate & tidal volume Used as primary ventilator mode or weaning mode |
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Ventilator Settings
Tidal Volume (VT) |
Volume of air delivered each breath
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Ventilator Settings
Rate (IMV) |
# of breath/minute( common setting 10-14 BPM)
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Ventilator Settings
Fraction of inspired O2 (FIO2) |
Oxygen concentration (21% (room air) to 100%)
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Ventilator Settings
Positive End-Expiratory Pressure (PEEP) |
Decrease the work of breathing
Improve oxygenation and ventilation Keeps alveoli open between breaths Treatment for persistent hypoxemia Complications-hypotension – nurse needs to closely monitor blood pressure COPD patients are at risk for pneumothorax because their alveoli are already expanded |
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Ventilator Settings
Continuous Positive Airway Pressure (CPAP) |
Used during weaning
Must have spontaneous respirations Intubation or tight fitting mask Positive pressure during the entire respiratory cycle Nasal CPAP,BIPAP |
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Ventilator Settings
Pressure Support (PSV) |
Respiratory support delivered during inspiration
Eases the work of breathing May be used in addition to PEEP or alone |
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Ventilator Alarms
Peak Airway (Inspiratory) Pressure (PIP) |
Pressure needed to deliver set tidal volume
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Ventilator Alarms
High pressure |
Coughing
Secretions Water in circuit tubing |
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Ventilator Alarms
Low pressure |
Circuit tubing loose or disconnected
ET cuff leak – nurse never inflates the cuff Patient extubated self |
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Complications of ventilators
Cardiac |
Hypotension – biggest problem, kidneys will kick in and cause fluid retention and fluid can go to the lungs
Fluid retention |
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Complications of ventilators
Pulmonary |
Barotrauma – damage from too much pressure related to PEEP settings
Volutrauama – too much tidal volume delivered to lungs Ventilatory dependence – especially with COPD, can be physiological or psychological |
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Complications of ventilators
Gastric/Nutrition |
Stress ulcer
Malnutrition – special tube feedings, Pulmacare – high protein and fat but low carbohydrate because carbs break down into CO2 |
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Complications of ventilators
Muscular |
Immobility
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Complications of ventilators
Infection |
VAP (Ventilator associated Pneumonia)
Occurs in 10-25% of vent clients, occurs within 48 hrs of intubation 33-50% mortality rate Develops within 48 hours of intubation Chg in pulmonary infiltrates on CXR, ↑WBC & temp, purulent secretions Prevention Measures Oral Care every 2-4 hours Brushing teeth & tongue with oral suction toothbrush Oral suctioning as needed & prior to deflating cuff or repositioning tube Apply mouth moisturizer Lip balm as needed Semi fowlers positioning In-Line Suction (Closed Unit) ↓ risk of ventilator associated pneumonia (VAP) Clean gloves Changed every 24-48 hours with ventilator circuit |
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Weaning from ventilators
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Ventilator support to re-establishing spontaneous, independent breathing, start weaning oxygen first, then rate, and then volume last
Mechanical ventilation AC to SIMV and PSV T-piece Extubation |
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Nursing Care of the Extubated Client
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Monitor oxygen saturation, respiratory rate and effort
Pulmonary Toilet Provide rest to ease the work of breathing OOB |
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Failure to Wean
Some clients cannot be weaned from the ventilator Causes : |
Underlying disease
Prolonged hospitalization secondary to multisystem organ failure Malnutrition Recent aspiration Electrolyte abnormalities Infection Care for those who cannot be weaned May be cared for in specialized respiratory unit in a hospital, a long-term care facility or at home Acute care needs must be resolved before transfer Few clients able to be cared for at home Lack of suitable space Lack of significant other who can assume responsibility for the ventilator 24 hrs/day |
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Choosing to be taken off the ventilator
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Client/family decision
Multidiciplanary Meeting Sedation for anxiety Comfort measures; Hospice encouraged |
